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Objective: Extremely thin and overly obese patients may not tolerate cardiac surgery as well as other patients. A retrospective study was conducted to determine whether the extremes of body mass index (weight/height2 [kg/m2]) and/or cachexia increased the morbidity and mortality associated with cardiac operations. Methods: Body mass index was used to objectively measure “thinness” (body mass index < 20) and “heaviness” (body mass index > 30); preoperative serum albumin was used to quantify nutritional status and underlying disease. Data were gathered between 1993 and 1997 from 5168 consecutive patients undergoing coronary artery bypass or valve operations, or both. Results: No significant correlations were observed between body mass index and preoperative albumin levels. Low body mass index (

Although externally exposed ventricular assist devices are associated with extremely high mortality rates, salvage may be accomplished by early aggressive wound debridement, transposition of a well-perfused autologous tissue (such as omentum), dead space obliteration, and adequate external coverage using vascularized tissue. The temporary suppression rather than the total eradication of the infection should be the goal of these procedures.

Background . The entire experience with the Hancock modified orifice porcine bioprosthetic aortic valve from 1976 to 1996 at the Brigham and Women's Hospital has been reviewed. Eight hundred forty-three patients received this valve with a total follow-up of 61,114 months, and a mean follow-up of approximately 72.5 months. There were 490 men and 353 women, and the predominate lesion was aortic stenosis (636 of 843); 365 (43%) patients required a concomitant coronary artery bypass graft operation. Methods . Patients were followed prospectively in the Brigham Cardiac Valve Data Registry, and the data were analyzed by the SAS statistical package, using actuarial survival curves and incidence per patient-year of morbidity and mortality. Results . The overall operative mortality was 45 of 843 (5.3%) with 23 of 478 (4.8%) for isolated aortic valve replacement and 22 of 365 (6.0%) for aortic valve plus coronary artery bypass graft operation. The major morbidity of this valve was structural valve dysfunction, which was significantly related to the age of the patient in whom the valve was placed. Actuarial probability of freedom from structural valve degeneration at 5, 10, and 15 years overall was 99% ± 1%, 79% ± 3% and 57% ± 4%, at 15 years, respectively. In patients younger than 50 years, freedom from structural valve dysfunction was 16% ± 8%, whereas in the age group older than 70 years it was 87% ± 5% ( p = 0.0005). Thromboembolism at 10 and 15 years was 81% ± 3% overall, 84% ± 2% in patients in normal sinus rhythm, and 57% ± 13% in patients with chronic atrial fibrillation. Conclusions . The Hancock modified orifice aortic valve, despite its more complicated fabrication, has been a reliable porcine bioprosthetic valve and can be used reliably in patients older than 70 years because of its low structural valve degeneration rate, and protection from stroke and anticoagulant hemorrhage in those patients in sinus rhythm.

Objectives: Our objective was to determine whether direct-access minimally invasive mitral valve surgery can improve recovery and cost while maintaining the efficacy of conventional surgery. Methods: Minimally invasive mitral valve operations were performed on 106 patients, 58% male, average age 58.1 years, with good ventricular function. Ninety underwent repair of a regurgitant, myxomatous valve, and 16 underwent mitral valvuloplasty for prematurely calcified mitral stenosis. The valve was approached with standard instruments through a 5- to 8-cm right parasternal incision. Eighty-five had open femoral artery–femoral vein cannulation, but this technique has recently been replaced by direct cannulation of the aorta and percutaneous cannulation of the femoral vein for most patients. Results: There were no operative deaths. The mean mitral regurgitation score (0-4) decreased from 3.7 to 0.7 after the operation. Although ischemic and bypass times were increased, postoperative recovery was accelerated. Ventilatory support time, intensive care unit stay, hospital stay, need for rehabilitation, and return to "normal activities" all improved. Hospital charges, pain medications, and blood transfusions were also reduced. New atrial fibrillation contributed significantly to increased length of stay and charges. There were no deep wound infections. Other complications included re-exploration for bleeding (n = 1), transient ischemic attacks (n = 2), stroke (n = 1), femoral artery injury (n = 5), pseudoaneurysm (n = 2), and antegrade dissection of the ascending aorta (n = 1). Two patients died and 1 required reoperation during a mean follow-up of 8.8 months. Conclusions: Direct-access minimally invasive mitral valve surgery can accelerate recovery, decrease charges, and decrease pain, while maintaining overall surgical efficacy. It has become our standard approach for isolated primary mitral valve operations. (J Thorac Cardiovasc Surg 1998;116:705-15)

Dynamic cardiomyoplasty (DCM) is an emerging surgical procedure for heart failure in which the patient's latissimus dorsi (LD) muscle is wrapped around the heart and stimulated to contract in synchrony with the heartbeat as a cardiac assist measure. A 6 week training protocol of progressive electrical stimulation renders the normally fatigueable skeletal muscle fatigue-resistant and suitable for chronic stimulation. To date, over 500 procedures have been performed in worldwide clinical trials. Investigators typically report symptomatic improvement and modest hemodynamic improvement in patients. Controversy exists regarding the exact mechanism of DCM. To test the hypothesis that DCM augments cardiac stroke volume through improvement in systolic function, we formulated an engineering model of dynamic cardiomyoplasty to predict stroke volume. The heart and the LD were modeled as nested (series) elastance chambers, and the vasculature was represented by a two-element Windkessel model. Using five healthy goats, we verified model predictions of stroke volume for both stimulator ON beats (y = 1.00x-0.08, r = 0.87, p0.0001) and OFF beats (y = 1.01x+1.06, r = 0.91, p0.0001), where x and y are the measured and predicted stroke volumes, respectively. The model confirms that using untrained latissimus dorsi applied to the normal myocardium produces only moderate increases in stroke volume and suggests that future research should focus on increasing LD strength after training.

In 2005, the investigators described a "hybrid" cardiovascular interventional strategy combining percutaneous coronary intervention (PCI) for coronary artery disease (CAD) followed by valve surgery for patients with urgent complex CAD and valve disease to reduce morbidity and mortality. This hybrid approach has been extended prospectively in elderly, high-risk patients with aortic stenosis scheduled for elective minimally invasive aortic valve replacement (MI-AVR) who, on preoperative coronary angiography, were found to have moderate CAD amenable to PCI. In this prospective, observational series, 18 patients (mean age 76 years) underwent elective hybrid MI-AVR with PCI from May 2003 to February 2006. Five patients had undergone previous coronary artery bypass grafting. Patients underwent coronary angiography the day of (n = 12) or evening before (n = 6) MI-AVR, and after identifying moderately severe CAD, all 18 underwent the implantation of drug-eluting stents to the affected coronary arteries, followed by MI-AVR. Although all patients received standard doses of antiplatelet medications, including acetylsalicylic acid (325 mg before PCI and 325 mg/day thereafter) and clopidogrel (300 mg after PCI, 75 mg/day thereafter for 90 days for the Cypher stent), there were no reoperations for bleeding; only 8 of 18 patients required postoperative blood transfusions. One patient died postoperatively from a colonic perforation, and there were no late mortalities after a mean follow-up of 19 months. In conclusion, this hybrid strategy has low morbidity and mortality and may be a new therapeutic option for older, high-risk patients with combined CAD and aortic valve disease.

Outer Loop Tachycardia. Introduction: Ventricular tachycardia (VT) alter postinfarct ventricular septal defect (VSD) repair has not been well characterized. Methods and Results: A 55-year-old man developed refractory VT after inferior wall infarction and VSD repair. Entrainment demonstrated a broad reentry circuit path (outer loop) between the tricuspid annulus and VSD patch. A series of radiofrequency (RF) lesions transected this path, abolishing VI’ and producing conduction block between the inferior and superior aspects of the basal right ventricular septum. Conclusion: Some VTs have broad reentry loops requiring ablation by a series of RF lesions across the path to create a line of block. This approach is analogous to that for atrial flutter.

Background . Peripheral arterial and venous cannulation for cardiopulmonary bypass is used increasingly for patients undergoing minimally invasive cardiac operations, complex reoperations, or repair of aortic dissection or aneurysm, and for patients with extensive arteriosclerotic aortic disease in whom aortic cannulation is a prohibitive embolic risk. The common femoral artery and vein are most commonly used for peripheral cannulation, but these sites may be predisposed to complications, primarily because the femoral vessels are commonly involved with arteriosclerotic disease. We have recently begun to use the axillary artery and axillary vein as alternative cannulation sites, achieving full cardiopulmonary bypass, providing antegrade aortic flow, and avoiding many of the complications associated with other sites. Methods . Seven patients with peripheral vascular or aortic disease, or both, prohibiting safe aortic or femoral cannulation underwent cardiopulmonary bypass through axillary artery and axillary vein cannulation, approached through a small single subclavicular incision. Results . All patients were successfully cannulated and axilloaxillary cardiopulmonary bypass was possible without the need for additional cannulas. All axillary vessels were closed primarily without complication. Conclusion . For an expanding population of patients with peripheral vascular and aortic disease, axilloaxillary bypass is a safe and practical alternative to aortic or femoral cannulation.

Background— Epicardial approaches have increased ablation success in nonischemic cardiomyopathy, but the use for postinfarction ventricular tachycardias (VT) is less clear. We report the findings for epicardial VT ablation in postinfarct patients. Methods and Results— Records of 444 consecutive patients with VT because of prior infarction referred for 600 catheter ablation procedures were reviewed. Epicardial procedures were performed in the electrophysiology laboratory in 56 (13%) patients using percutaneous (43 patients) or surgical (13 patients) epicardial access. In 7 patients, epicardial ablation was performed surgically in the operating room. In the electrophysiology laboratory epicardial VT targets were identified in 38 (68%) patients and epicardial ablation abolished ≥1 VT in 27 patients (6% of the total study population); inducibility was not tested after ablation in 4, and VT remained inducible in 7 patients. No ablation was performed in 18 (32%) patients because of no accessible epicardial target or a complication. Major complications occurred in 8 (14%) of the 57 electrophysiology laboratory procedures. After the first procedure any VT recurred in 21 (54%) of 39 patients who had epicardial ablation compared with 164 (47%) of 347 endocardial-only ablation patients ( P =0.35). Conclusions— Epicardial ablation is potentially useful in ≥6% of the postinfarction VT population, but the number could be substantially greater because more than two thirds of patients selected for epicardial mapping after failed ablation had an epicardial VT target. Successful epicardial ablation of a VT was not predictable from infarct location or other patient characteristics.

Background Chronically supported left ventricular assist device (LVAD) patients may be candidates for novel therapies aimed at promoting reverse remodeling and myocardial recovery. However, the effect of hemodynamic unloading with a LVAD on myocardial viability and LV function in chronically supported LVAD patients has not been fully characterized. We aimed to develop a non-invasive imaging protocol to serially quantify native cardiac structure, function, and myocardial viability while at reduced LVAD support. Methods Clinically stable ( n = 18) ambulatory patients (83% men, median age, 61 years) supported by a HeartMate II (Thoratec, Pleasanton, CA) LVAD (median durations of heart failure 4.6 years and LVAD support 7 months) were evaluated by echocardiography and technetium-99m ( 99m Tc)-sestamibi single photon emission computed tomography (SPECT) imaging at baseline and after an interval of 2 to 3 months. Echocardiographic measures of LV size and function, including speckle tracking–derived circumferential strain, were compared between ambulatory and reduced LVAD support at baseline and between baseline and follow-up at reduced LVAD support. The extent of myocardial viability by SPECT was compared between baseline and follow-up at reduced LVAD support. Results With reduction in LVAD speeds (6,600 rpm; interquartile range: 6,200, 7,400 rpm), LV size increased, LV systolic function remained stable, and filling pressures nominally worsened. After a median 2.1 months, cardiac structure, function, and the extent of viable myocardium, globally and regionally, was unchanged on repeat imaging while at reduced LVAD speed. Conclusions In clinically stable chronically supported LVAD patients, intrinsic cardiac structure, function, and myocardial viability did not significantly change over the pre-specified time frame. Echocardiographic circumferential strain and 99m Tc-sestamibi SPECT myocardial viability imaging may provide useful non-invasive end points for the assessment of cardiac structure and function, particularly for phase II studies of novel therapies aimed at promoting reverse remodeling and myocardial recovery in LVAD patients.

Background As waiting time for heart transplantation has increased, ventricular assist devices have become critical for "bridging" patients with end-stage heart failure. Because most reported post-discharge experience is with left ventricular assist devices (LVAD), we sought to evaluate the safety and feasibility of home discharge on paracorporeal biventricular assist devices (BIVAD). Methods We retrospectively reviewed the hospital course and post-discharge outcomes of 46 consecutive patients who received paracorporeal VADs as bridge to transplant. The success of home discharge was assessed by frequency and reasons for hospital readmission and survival to transplant. Results Thirty patients (65%) were successfully transferred from the intensive care unit and considered candidates for discharge. Of the 26 patients discharged home, 11 were supported with an LVAD and 15 with BIVADs. Median duration of support until transplant, explant, or death did not differ significantly between LVAD or BIVAD patients (91 days vs 158 days; p = 0.09). There were 26 readmissions for medical or device-related complications; 10 in 7 LVAD patients and 16 in 10 BIVAD patients, with no difference in median length of stay (17 days vs 25 days; p = 0.67). Out of hospital duration of support was similar between LVAD and BIVAD patients (61 days vs 66 days; p = 0.87) as were 6-month and 1-year event-free survival rates ( p = 0.49). Conclusions Outcomes were similar in patients bridged to transplant on home paracorporeal BIVAD versus LVAD support. We recommend discharge for stable patients demonstrating device competency and adequate home care regardless of the need for univentricular or biventricular paracorporeal support.

Background. This study was done to answer the question, "What is the current risk of resection of ascending aortic aneurysms regardless of acuity or cause?" Methods. One hundred fifteen consecutive patients who underwent ascending aortic aneurysm repair from January 1, 1990, to July 1, 1995, were retrospectively reviewed, excluding those with acute ascending aortic dissection. The mean age was 59 years; 55% were male. Concomitant procedures included coronary artery bypass in 23 (20%) and arch repair in 12 (10%). In group 1, 54 patients had replacement of the aortic valve, root, and ascending aorta with a valve-graft conduit using the "Bentall" technique, and of these 19 (35%) had Marfan's syndrome. In group II, 44 patients had separate aortic valve repair or replacement and supracoronary ascending aortic replacement. In group III, 17 patients had supracoronary ascending aortic replacement, without aortic valve operation. Operative techniques included frequent use of (1) intraoperative transesophageal echocardiography or epiaortic ultrasound scanning of the ascending and descending thoracic aorta to help guide arterial cannulation, avoid atherosclerotic embolization, and assess the repair; (2) antegrade and retrograde multidose cold blood cardioplegia for myocardial protection; (3) exclusion and button anastomotic techniques to ensure secure suture lines; (4) antifibrinolytic agents and collagen-impregnated aortic grafts to reduce bleeding; and (5) deep hypothermic circulatory arrest and the open distal anastomotic technique in patients with distal ascending and arch aortic disease. Results. Operative mortality overall was 2/115 (1.7%). Mortality was 1/54 (1.8) in group I and 1/44 (2%) in group II, and there was no mortality in group III. The overall postoperative morbidity was 3% due to bleeding, 2% due to stroke, and 1% due to myocardial infarction. The length of stay in the past year has decreased to less than 7 days. Conclusions. The current risk for ascending aortic aneurysm repair is low (

Background Infective mitral valve endocarditis continues to be a significant surgical challenge. The objective of this study was to examine our experience with mitral valve endocarditis surgery and identify determinants of early mortality and late survival. Methods and Results Over a 24-year period, mitral valve surgery was performed in 96 patients for infective mitral valve endocarditis. Patient age ranged from 20 to 78 years (median age, 52 years). There were 44 women (46%), and 48 of the 96 patients (50%) were in New York Heart Association functional class IV before surgery. Native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) were present in 72 patients (75%) and 24 patients (25%), respectively. Surgery during the active phase of endocarditis (AE) was required in 60 patients (62%) and during the healed phase (HE) in 36 (38%). The main indications for surgery in the AE group were congestive heart failure (60%), active sepsis (67%), peripheral emboli (47%), and acute renal failure (20%), and for the HE group the main indication was progressive congestive heart failure (69%). The overall operative mortality was 5.2%. Multivariate logistic regression analysis identified PVE (odds ratio [OR] 22.5; ±95% confidence interval, CI, 1.9 to 268; P =.014) and an associated procedure (OR 13.3; ±95% CI, 1.5 to 120; P =.021) to be independent predictors for early mortality. Follow-up was 97% complete, with a median of 3.5 years. Overall 5- and 10-year survivals were 83±4% and 63±8%, respectively. Multivariate analysis for late mortality identified PVE to be a significant predictor of late mortality (hazards ratio=3.1, ±95% CI, 1.4 to 6.8, P =.006). There were no significant differences in long-term morbidity results among the various subsets of mitral valve endocarditis. Conclusions Mitral valve surgery for infective endocarditis is a significant high-risk procedure for PVE and when combined with associated procedures. The activity of endocarditis does not appear to have any influence on early mortality or long-term survival.

Abstract We studied several aspects of guanine nucleotide–stimulated adenylate cyclase function in patients after orthotopic cardiac transplantation. In 28 patients, adenylate cyclase activity was measured in endomyocardial biopsy samples obtained just before and at monthly intervals after cardiac transplantation. In biopsies obtained ≥6 months after transplantation, basal adenylate cyclase activity was decreased by 67% (n=12; P P +2 +forskolin–stimulated adenylate cyclase activity was decreased by 80% (n=8; P +2 -stimulated adenylate cyclase activity (a measure of activity of the catalytic subunit of adenylate cyclase) was decreased by 83% (n=8, P sα protein was decreased by 61±12% (n=8; P iα as assessed by pertussis toxin–catalyzed ADP-ribosylation (n=4; P =NS). With the use of the quantitative polymerase chain reaction, a 50±10% (n=6; P sα mRNA was observed. There was no change in the level of mRNA for G i-3α . Thus, after orthotopic cardiac transplantation in humans, guanine nucleotide–stimulated adenylate cyclase activity is decreased in parallel with decreased levels of G sα protein and mRNA.

Patients with diabetes mellitus have an increased frequency of atherosclerotic coronary artery disease, plus abnormalities of vascular tone that could be contributed to autonomic, platelet, and endothelial dysfunction. The purpose of this prospective study was to compare the internal thoracic artery (ITA) flow of diabetic and nondiabetic patients, to determine whether any pathophysiologic changes occur that have any bearing on vascular tone and the adequacy of flow of the ITA. In a consecutive group of patients undergoing coronary artery bypass graft (CABG) surgery, 117 patients (group I) were nondiabetic (ND), 18 patients (group II) were noninsulin dependent (NIDDM), and 20 patients (group III) were insulin dependent (IDDM) diabetics. The ITA was mobilized, and following systemic heparinization it was divided and trimmed for the subsequent anastomoses. The first ITA flow measurement was recorded (flow 1). This was followed by an intraluminal injection of 2 mL of dilute papaverine solution (30 mg in 20 mL N/saline), which was enclosed in the artery for fifteen minutes by applying a soft clamp to the distal end. At the end of this period, a second flow measurement was taken (flow 2). Percent increase in flow and flow reserve (flow 2/flow 1) were recorded for each patient. The median values for flow 1 were 48, 46, and 58 mL/minute for groups I, II, and III respectively. For flow 2 the values were 132, 118, and 126 for groups I, II, and III, respectively, with a median percent increase in flow being 138% (47-380%), 179% (100-380%), and 115% (35-470%) for groups I, II, and III respectively (P < 0.0001). ITA flow reserve was similar among the three groups and was 2.4, 2.8, and 2.2 for groups I, II, and III respectively. The ITA exhibits the same degree of initial spasm, similar relaxation to intraluminal papaverine, and similar flow reserve. No physiologic abnormalities of ITA flow and reactivity are specific to diabetes. The ITA should be used with the same indications or contraindications as in nondiabetic patients.

Gastrointestinal bleeding (GIB) is reported in up to 30% of patients with continuous flow left ventricular assist devices (LVADs). We hypothesized that episodes of GIB in patients with LVAD are associated with significant in-hospital resource utilization and that investigations are often unrevealing

After 3 days of nausea and dyspnoea, a 62-year-old man was found to have a completed inferior myocardial infarction. Angiography demonstrated right coronary artery occlusion, and no intervention was performed. Several days later, he had worsened dyspnoea and syncope due to pericardial haematoma. This prompted emergent surgical evacuation and patch repair of a 2-cm inferior wall rupture. Three months later, he presented …

Angiography has been considered the gold standard, for the diagnosis of acute dissection of the ascending aorta, but it may increase mortality by imposing an unnecessary delay before surgical repair. In addition, coronary angiography has often been considered essential as well. From 1988 to 1993, 37 patients (median age 61 years, 30 men and 7 women) had acute dissection of the ascending aorta. All of the initial 15 patients (group I) had angiography, even though the diagnosis , of aortic dissection had already been made noninvasively in 14; six (40%) of 15 died, three of aortic rupture and none of complications of coronary artery disease. Among the next 22 patients (group 11), 21 had a noninvasive diagnosis of acute dissection of the ascending aorta (eight by echocardiography; 13 by computed tomography), and 19 (86%) were operated on without angiography; two died (9%, p = 0.03 versus group I) and neither death was due to aortic rupture ,or coronary artery disease. Overall, either root or selective coronary angiography was attempted in 18 of 37 patients, but it documented coronary artery disease in only two patients (11%). Coronary artery disease was found in four other patients at autopsy; three of them, including two that died of aortic rupture, had angiography that failed to reveal the coronary artery disease. Noninvasive diagnosis of acute dissection of the ascending aorta is reliable and avoids the risks and delays inherent in invasive angiography. Rapid noninvasive diagnosis of aortic dissection and avoidance of routine angiography appear to improve survival by expediting surgical intervention and thus decreasing the risk of aortic rupture.

Objectives . The aim of this study was to determine the etiologic factors in the formation of significant pericardial effusion after orthotopic heart transplantation and to determine the association of pericardial effusion with survival. Background . The formation of pericardial effusions has been well described after orthotopic heart transplantation, but the risk factors for development of effusions remain unclear. Rejection and cyclosporine have been cited as possible causes, but anatomic factors bave not been studied. Methods . We conducted a retrospective review of medical records and echocardiograms of 203 consecutive patients at one center, including ischemic time, incidence and severity of rejection, weight difference between donor and recipient and previous cardiac surgical history. Multivariate analysis was performed, and actuarial survival rate curves were calculated according to the Kaplan-Meier method. Results . Eighteen (8.9%) of 203 transplant recipients developed moderate to large pericardial effusions. Forty-four percent of patients required pericardiocentesis, and 28% subsequently required pericardiectomy for management of the effusions. Multivariate analysis identified the presence of a positive weight difference between recipient and donor (recipient weight > donor weight) and the lack of previous median sternotomy as the most powerful predictors of effusion formation. No significant association was found with rejection. There was no difference in actuarial survival rate between patients with and without effusions. Conclusions . A positive mismatch in weight between recipient and donor and the absence of previous cardiac surgery are associated with the formation of significant pericardial effusions. Closer monitoring of these patients at risk may be warranted.

The myxomatous, degenerated, prolapsed or "floppy" mitral valve is the most common cause of mitral regurgitation in North America. Mitral valve reconstruction for mitral regurgitation was carried out in 219 consecutive patients with a myxomatous mitral valve from 1984 to 1993. Of the 139 men and 80 women, 23 to 84 years of age (mean 63 years), 36% of patients were 70 years of age or older, 77% were in New York Heart Association functional class III or IV, and 29% had coronary artery disease necessitating coronary bypass. The most common operation was posterior leaflet resection (161 patients [73%]). The anterior leaflet was resected in 14 patients, and both the anterior and posterior leaflets were resected in 15 patients. A variety of other techniques were used, including commissuroplasty and use of annuloplasty rings. A flexible Duran ring was used in 111 patients (51%), a Carpentier-Edwards ring in 44 patients (20%), and no ring was used in 64 patients (29%). Five operative deaths occurred (2.3%); four of the five deaths occurred in patients 70 years of age or older (5.1%); and one in 141 patients (0.7%) was younger than 70 years of age. In the late postoperative period (mean follow-up 2 years), 90% of patients had no symptoms, two had endocarditis, and seven patients had thromboemboli (transient in four, permanent in three). Structural valve degeneration requiring reoperation occurred late in 12 patients; eight were in posterior leaflet resection and two in anterior or anterior and posterior; six of 12 had no annuloplasty ring. The incidence of structural valve degeneration was less than 5% from 1990 to 1993. No systolic anterior motion of the mitral valve was seen with postoperative echocardiography before discharge. Actuarial analysis at 5 years for overall survival was 86% ± 5%, freedom from infectious valve degeneration 97% ± 2%, and freedom from thromboembolism 94% ± 3%. Freedom from structural valve degeneration overall was 83% ± 4%, with a flexible ring it was 89% ± 6%, with a rigid ring it was 88% ± 6%, and with no ring it was 67% ± 12% ( p = 0.03). Mitral valve reconstruction for complicated myxomatous disease of the mitral valve, regardless of leaflet involvement, is feasible and offers excellent early and late results. (J T HORAC C ARDIOVASC S URG 1994;107:143-51)

Sustained monomorphic ventricular tachycardia (VT) in patients with heart disease is usually due to reentry involving a region of myocardial scar. Most commonly, the scar is due to prior myocardial infarction and associated with significantly depressed left ventricular function. Scars create a very stable substrate for VT, such that up to 70% of patients who present with sustained monomorphic VT late after myocardial infarction will have another episode within the next 2 years.1,2 Scars also occur in patients with nonischemic dilated cardiomyopathies (NICM) but are generally small, averaging less than 4% of the ventricular myocardium in one study using MRI.3 Replacement fibrosis is a likely mechanism. Consistent with the less frequent and smaller areas of confluent scar in nonischemic cardiomyopathies, sustained monomorphic VT is relatively infrequent. In patients with depressed left ventricular function who received an implantable cardioverter-defibrillator (ICD) for primary prevention, 15% had spontaneous VT or ventricular fibrillation detected by the ICD during a follow-up of 29 months, and approximately half of these arrhythmias were monomorphic VT.4 Article see p 494 Because large scars are not common in NICM, the possibility of bundle-branch reentry, which may occur without large scars, is an important consideration when sustained VT is encountered but accounts for fewer than 10% of VTs in this patient population.5 It has become increasingly clear that ventricular scars are a major factor causing sustained monomorphic VT in patients with NICM.6,7 Of patients who have recurrent episodes of VT, who are considered for catheter ablation, the vast majority have evidence of ventricular scars, based on voltage mapping or late Gd enhancement (LGE) on MRI.8 …

Recent technological advances in cardiopulmonary bypass circuits achieving surface bonding with heparin have permitted prolonged extracorporeal life support (ECLS) in experimental studies without the use of systemic anticoagulation. Excessive bleeding and the need for massive transfusions after extended ECLS with systemic heparinization have often led to the development of sepsis and multisystem organ failure. The Carmeda bioactive surface circuit, along with a Bio-Medicus centrifugal pump (Bio-Pump) and the femoral veno-arterial route, were used successfully in 3 patients requiring ECLS between April 1992 and December 1992. In 2 patients the need for ECLS was acute allograft dysfunction after orthotopic cardiac transplantation with no evidence of cellular rejection. Both patients were receiving multiple inotropes and intraaortic balloon counterpulsation; their condition continued to deteriorate rapidly before the initiation of ECLS. The third patient failed to be weaned from cardiopulmonary bypass after myocardial rcvascularization for ischemic cardiomyopathy. Time on ECLS ranged from 57 to 128 hours. No systemic anticoagulation was used. One patient received no heparin, and the other 2 patients received intermittent heparin infusion to maintain an average activated clotting time of 195 and 214 seconds. Multisystem organ dysfunction present before initiation of ECLS was rapidly reversed, and all patients were weaned successfully without any immediate major complications. The ability to conduct prolonged ECLS without systemic anticoagulation and without repeat sternotomy opens new avenues for the use of this procedure in profound heart failure.

After crystalloid cardioplegic arrest, cardiac-derived thromboxane A2 may be an important initiating mediator of no-reflow and hemodynamic deterioration during reperfusion because of its potent vasoactive properties. Although previous studies have already documented the increased release of cardiac thromboxane A2 after ischemia, none have studied the effects of cardiac thromboxane A2 on hemodynamics. We therefore tested the ability of cardiac thromboxane A2 to mediate deterioration of coronary flow and functional recovery during reperfusion after global ischemia. Crystalloid-perfused rat hearts that had undergone Langendorff preparation (n = 30) were subjected to 2 hours of global ischemia at 15° C under cardioplegic protection with (n = 15) or without (n = 15) thromboxane A2 receptor antagonist SQ29548. In eight of 15 hearts in each group, preischemic and postischemic aortic flow, coronary flow, cardiac output, heart rate, and stroke work were determined. In the remaining seven hearts in each group, preischemic and postischemic coronary effluent levels of the stable hydrolysis product of thromboxane A2 and thromboxane B2 were determined with radioimmunoassay through the use of nonrecirculating perfusate. At the completion of the experiment, water content was determined by wet weight/dry weight calculations. In a separate group (n = 7) preischemic myocardial water content was determined. Within the group protected by cardioplegic solution alone, postischemic aortic flow, coronary flow, cardiac output, and stroke work were all significantly decreased (p

From the Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA Thrombosis and thromboembolism are an increasingly recognized source of early postoperative morbidity following institution of mechanical circulatory support. We report an unusual case of aortic root thrombus occluding the left main coronary artery four days after implantation of an axial continuous flow HeartMate II (Thoratec, Pleasonton, CA USA) left ventricular assist device (LVAD). A 48-year old man with refractory, inotrope-dependent heart failure due to idiopathic dilated cardiomyopathy underwent elective LVAD implantation as a bridge to cardiac transplantation. Aspirin 325mg was initiated within 24 hours of surgery and unfractionated intravenous heparin (target partial thromboplastin time 60-80 seconds) was started within 36 hours. Lactate dehydrogenase was measured at 502 U/L. On the fourth postoperative day, an echocardiogram was performed for LVAD speed and flow optimization. The pump speed was decreased from 9600 RPM to 8600 RPM until intermittent aortic valve opening was achieved; immediately after the pump speed was reduced, the patient had abrupt onset of nausea, dyspnea and left shoulder discomfort. An electrocardiogram revealed 4mm ST-segment elevations in leads V2-V6 consistent with anterior myocardial injury. The patient underwent emergent coronary angiography, which revealed thrombotic obstruction of the terminal portion of the left anterior descending (LAD) coronary artery, but no proximal disease. Root aortography revealed a thrombus in the left coronary cusp obstructing the left main coronary artery ostium (Figure 1). Transesophageal echocardiography confirmed the presence of a thrombus in the left coronary cusp with dense spontaneous echo contrast noted throughout the aortic root (Figure 2). A guide catheter was left engaged in the left main coronary artery to protect against recurrent Figure 1 Contrast injection in the aortic root revealing thrombus in the left coronary cusp partially obstructing the left main coronary artery.

We describe a technique for blood conservation when ABIOMED BVS 5000 blood pumps require exchange because of thrombus formation in the blood pumps. The technique is simple in concept but requires careful planning and coordination between surgeon and perfusionist.

Ventricular assist device (VAD) support inpatients with a prosthetic heart valve had previously been considered a relative contraindication due to an increased risk of thromboembolic complications. We report our clinical experience of VAD implantation in patients with prosthetic heart valves, including both mechanical and bioprosthetic valves. The clinical records of 133 consecutive patients who underwent VAD implantation at a single institution from January 2002 through June 2009 were retrospectively reviewed. Six of these patients had a prosthetic valve in place at the time of device implantation. Patient demographics,operative characteristics, and postoperative complications were reviewed.Of the six patients,four were male.The mean age was 57.8 years (range 35–66 years). The various prosthetic cardiac valves included a mechanical aortic valve (n = 2), a bioprosthetic aortic valve (n = 3), and a mechanical mitral valve (n = 1).The indications for VAD support included bridge to transplantation (n = 2), bridge to recovery (n = 1), and postcardiotomy ventricular failure(n = 3). Three patients underwent left ventricular assist device placement and three received a right ventricular assist device. Postoperatively, standard anticoagulation management began with a heparin infusion (if possible)followed by oral anticoagulation.The 30-day mortality was50% (3/6). The mean duration of support among survivors was 194.3 days (range 7–369 days) compared with 16.0 days(range 4–29 days) for nonsurvivors. Of the three survivors,two were successfully bridged to heart transplantation and one recovered native ventricular function.Among the three nonsurvivors,acute renal failure developed in each case, and two developed heparin-induced thrombocytopenia. This study suggests that VAD placement in patients with a prosthethic heart valve, either mechanical or bioprosthetic,appears to be a reasonable option.

This study tested the hypothesis that preventing neutrophil adhesion during reperfusion, by blocking either the neutrophil membrane CD18 integrin complex or its endothelial and myocyte ligand, intercellular adhesion molecule-1 (ICAM-1), would reduce myocardial inflammation and edema and improve reflow and ventricular function after heart preservation and transplantation. After cardioplegia and insertion of a left ventricular balloon, rabbit hearts were heterotopically transplanted into recipient rabbits either immediately (immediate, n = 12) or after preservation in 4° C saline (3 hours of ischemia, n = 33). Forty-five minutes before reperfusion, recipients of preserved hearts received intravenous infusions of either saline (vehicle, n = 13), anti-CD18 monoclonal antibody (Mab) R15.7 (2 mg/kg) (anti-CD18, n = 10), or anti-ICAM-1 Mab R1.1 (2 mg/kg) (anti-ICAM, n = 10). During 3 hours of reperfusion the slope of the peak-systolic pressure-volume relation and its volume-axis intercept, the exponential elastic coefficient of the end-diastolic pressure-volume relation, the unstressed ventricular volume, and the time constant of the exponential left ventricular pressure decay after dP/dtmin were serially measured. Myocardial blood flow was measured with microspheres from which coronary vascular resistance was calculated. After explantation, the degree of myocardial inflammation, estimated by tissue neutrophil sequestration (myeloperoxidase assay) and myocardial water content were determined. Within each group no significant differences in measurements made at 1, 2, and 3 hours of reperfusion were noted. Compared with the immediate transplantation group, the vehicle group demonstrated a significant increase in myeloperoxidase activity (3380 ± 456 versus 1712 ± 552 μU/gm, p 0.05) and myocardial water content (anti-CD18, 75.2 % ± 1.7% versus 79.8% ± 0.4%, p 0.05). These results demonstrate the prevention of myocardial neutrophil sequestration, edema, the low-reflow phenomenon, and diastolic myocardial dysfunction by Mabs that block neutrophil adhesion. We conclude that neutrophil adhesion is an important mechanism of reperfusion-induced myocardial damage after heart transplantation and should be addressed in treatments directed at limiting reperfusion injury.

This study was designed to evaluate the distribution of cardioplegic solution infused antegradely with simultaneous coronary sinus occlusion. After 1 hr LAD occlusion, sheep were placed on cardiopulmonary bypass. Hearts were arrested with 300 ml of cold cardioplegia and replenished with two additional doses. In group I (n = 10), antegrade cardioplegia (ACP) was given alone; in group II (n = 9), ACP was given in combination with simultaneous coronary sinus occlusion. Microspheres were infused into the cardioplegic line to determine the antegrade distribution of the solution, while a different microsphere was injected into the anterior interventricular vein to detect the venous backflow of the solution. The data showed that myocardium distal to LAD occlusion in group II received more antegrade (0.17 +/- 0.02 versus 0.06 +/- 0.02 ml/g/min, P less than 0.01, in subendocardium; and 0.15 +/- 0.03 versus 0.09 +/- 0.02 ml/g/min, P = NS, in subepicardium) and retrograde (2181 +/- 455 versus 0 counts/g/min, P less than 0.01, in subendocardium; and 2,146 +/- 527 versus 0 counts/g/min, P less than 0.01, in subepicardium) distribution of cardioplegic solution in comparison to group I. We therefore conclude that simultaneous coronary sinus occlusion significantly improves the distribution of antegrade cardioplegic solution to the regionally occluded myocardium by increasing collateral flow as well as venous backflow.

Open-chest sheep underwent 90 minutes' occlusion of the diagonal branch of the left anterior descending coronary artery, followed by vented cardiopulmonary bypass. After 30 minutes of cardioplegic arrest, simulating distal anastomoses, the occlusion on the coronary artery branch was released. Controlled reperfusion (40 to 50 mm Hg, 135 to 150 ml/min) for the first 20 minutes was delivered at the aortic root with either unmodified whole blood (control, n = 7) or blood passed through leukocyte filters (filters, n = 7). Serial measurements were made during 3 additional hours reperfusion off cardiopulmonary bypass. During ischemia, the major determinants of infarct size, which include area at risk, collateral myocardial blood flow, and rate-pressure product were not significantly different between groups. Overall, during reperfusion, mean left ventricular stroke work index in the filter group was greater than in the control group (28.7 +/- 5.8 versus 12.6 +/- 6.4 x 10(3) erg/gm, p less than 0.05), as was mean rate of rise of left ventricular pressure (1900 +/- 260 versus 1348 +/- 279 mm Hg/sec, p less than 0.05). Myocardial blood flow to the area at risk at 3 1/2 hours of reperfusion in the filter group was also significantly better than in the control group (0.57 +/- 0.15 versus 0.27 +/- 0.05 ml/min/gm, p less than 0.05), as was necrotic area as a percentage of area at risk (40% +/- 6% versus 70% +/- 5%, p less than 0.05). These results demonstrate amelioration of myocardial stunning and the no-reflow phenomenon, as well as decreased infarct size. We conclude that controlled reperfusion with leukocyte-depleted blood is superior to whole-blood reperfusion for the surgical treatment of acute regional ischemia.

Background— The aortomitral continuity (AMC) has been described as a site of origin for ventricular tachycardias (VT) in structurally normal hearts. There is a paucity of data on the contribution of this region to VTs in patients with structural heart disease. Methods and Results— Data from 550 consecutive patients undergoing catheter ablation for VT associated with structural heart disease were reviewed. Twenty-one (3.8%) had a VT involving the peri-AMC region (age, 62.7�11 years; median left ventricular ejection fraction, 43.6�17%). Structural heart disease was ischemic in 7 (33%), dilated cardiomyopathy in 10 (47.6%), and valvular cardiomyopathy in 4 (19%) patients, respectively. After 1.9�0.8 catheter ablation procedures (including 3 transcoronary ethanol ablations) the peri-AMC VT was not inducible in 19 patients. The remaining 2 patients underwent cryosurgical ablation. Our first catheter ablation procedure was less often successful (66.7%) for peri-AMC VTs compared with that for 246 VTs originating from the LV free wall (81.4%, P =0.03). During a mean follow-up of 1.9�2.1 years, 12 (57.1%) patients remained free of VT, peri-AMC VT recurred in 7 patients, and 1 patient had recurrent VT from a remote location. Three patients died. Analysis of 50 normal coronary angiograms demonstrated an early septal branch supplying the peri-AMC area in 58% of cases that is a potential target for ethanol ablation. Conclusions— VTs involving the peri-AMC region occur in patients with structural heart disease and appear to be more difficult to ablate compared with VTs originating from the free LV wall. This region provides unique challenges for radiofrequency ablation, but cryosurgery and transcoronary alcohol ablation appear feasible in some cases.

The Hancock Modified Orifice valve is a specially fabricated, trileaflet porcine valve, which has been in clinical use at the Brigham and Women's Hospital since 1976. Three hundred seventy-nine aortic valve replacements with this device were implanted from 1976 to 1985; 305 were isolated aortic valve replacements and 74 were in association with a mitral valve bioprosthesis. The 305 patients undergoing isolated aortic valve replacement, a Food and Drug Administration patient group, are the subject of this article. The mean valve size was 22.5 mm, with 115 21-mm valves used. The mean functional preoperative class was 3.2; 99 of 305 patients (32.5%) underwent concomitant coronary artery bypass grafting. There were six operative deaths (2%). Patients were followed from 6-14 years (mean 7.4 years), and analysis was completed in early 1991. The 10-year actuarial calculation of survival freedom from reoperation, thromboembolism, structural valve degeneration, perivalvular leak, infectious valve degeneration, and total morbidity and mortality are presented.

There is controversy whether the short-term and long-term results of coronary artery bypass grafting in elderly patients justify performing the procedure. Between January 1977 and December 1986, 4580 patients underwent coronary artery bypass grafting, of whom 222 (4.9%) were 75 years old or older (mean 77 years). There were 143 men and 79 women and 139 (63%) were in New York Heart Association class IV. One hundred forty-six patients (66%) had had at least one preoperative myocardial infarction. Myocardial revascularization was performed under emergency conditions in 17 patients (18%). The mammary artery was used in 43%, 96% of the patients received two or more grafts. The mean number of bypass grafts was 3.1 per patient. The overall hospital mortality rate was 10.8% (24/222), 3.6% for elective procedures, 14.9% in urgent cases, and 35% in emergencies. In contrast, the overall early mortality rate was 3.1% in 4358 patients less than 75 years old. Complications occurred in 83 patients (37%). Of the patients discharged from the hospital, 198 were followed up for a mean of 48 months (1 to 130). Actuarial probability of survival was 75% at 48 months. Postoperatively 70% were in New York Heart Association class I or II and only 21% were rehospitalized for cardiac problems. During the follow-up period 77% of the patients were free from angina, and of those experiencing angina the mean time from operation to the first episode was 75 months. Although elderly patients have a somewhat increased operative mortality rate, particularly if operated on urgently or emergently, long-term survival and freedom from angina are excellent and justify continued performance of coronary bypass grafting in selected patients over 75 years of age.

The safety and benefit of minimally invasive aortic valve replacement in patients with left ventricular dysfunction has not been well investigated. We conducted a retrospective review of 140 patients with ejection fraction ≤ 40% who underwent isolated aortic valve replacement between July 1996 and March 2005. Aortic valve replacement was performed via an upper hemisternotomy in 73 patients and via a full sternotomy in 67. Two matched cohorts of 41 patients each were constructed using propensity score analysis, and the outcomes were compared. There was no significant difference in operative mortality (hemisternotomy, 2.4% vs 4.8% for full sternotomy), incidence of postoperative complications, blood transfusion requirement, length of hospital stay, or discharge to home rates. Aortic valve replacement via an upper hemisternotomy can be performed safely, even in patients with left ventricular dysfunction, with morbidity and mortality outcomes similar to those of a full sternotomy.

Purpose: Early risk stratification for pump thrombosis in continuous-flow left ventricular assist device (LVAD) therapy remains challenging. We hypothesized that the decrement in LV size prior to discharge after device implantation is associated with increased risk of pump thrombosis. Methods: In 65 patients (age 59±11 years, 79% men, 45% destination therapy) discharged alive without evidence of thrombosis or other device malfunction following first HeartMate II LVAD implantation (January 2011-June 2014), LV dimensions in end-diastole (LVIDd) and end-systole (LVIDs) were compared between pre-implantation and optimal set speed predischarge echocardiography. LV dimension decrement indices (preoperative dimension optimal set speed dimension divided by preoperative dimension x100) for LVIDd [LVIDdDI] and LVIDs [LVIDsDI] were calculated. Patients were followed for occurrence of confirmed or suspected (lactate dehydrogenase > 1000IU/l or 2.5x upper limit of normal ± evidence of pump dysfunction) LVAD thrombosis for the duration of therapy through November 2014. Results: Incidence of pump thrombosis was 0.07 per-patient-year (n= 18 patients overall). Median time to event was 8 (IQR 2, 17) months. Baseline preoperative LVIDd (p= 0.73) and LVIDs (p= 0.84) were similar between patients with and without LVAD thrombosis. Mean set speed (9240±300 vs. 9190±380 rpms, p= 0.60), other ramp parameters, and change in right heart indices between preoperative and set speed studies did not differ between groups. However, LVIDdDI (18±13 vs. 25±11%, p= 0.04) and LVIDsDI (16±16 vs. 28±13%, p= 0.006) were significantly lower in the pump thrombosis compared to no thrombosis group. On ROC curve analysis, AUC for association with LVAD thrombosis was 0.67 (0.52-0.82, p= 0.04) for LVIDdDI and 0.69 (0.55-0.83, p= 0.02) for LVIDsDI. A cut-off value of ≤ 15% for both indices had sensitivities of 82% (LVIDdDI) and 84% (LVIDsDI) for predicting pump thrombosis (specificities 41% and 35% respectively). Conclusion: LV Dimension Decrement Index measured at optimized speed setting on predischarge echocardiography is predictive of late pump thrombosis. This novel marker reflects intrinsic limitations to optimization of the LVAD/patient interface and identifies patients in whom more intensive surveillance for pump thrombosis may be indicated.

Background Minimal access approaches are becoming readily accepted techniques for cardiac valve surgery. However, the safety or benefit of this approach for aortic surgery has not been well investigated. Methods We retrospectively analyzed 128 consecutive patients who underwent ascending aortic replacement (n = 53), proximal aortic arch replacement (n = 7), aortic root replacement (n = 67), or sinus of Valsalva aneurysm repair (n = 1) through an upper hemisternotomy between August 1996 and May 2005. Using matched variables (age, type of procedure, redo operation, and use of circulatory arrest), we constructed two matched cohorts of 79 patients each: a minimally invasive (group A) and full sternotomy (group B) and compared outcomes. Results The mean age for the minimally invasive group (n = 128) was 54 years (range, 25 to 83 years). There were six reoperations (4.7%), five (3.9%) urgent operations, and 16 (12.5%) deep hypothermic circulatory arrests. Operative mortality was zero, the median length of hospital stay was 5 days (range, 3 to 21 days), and 112 patients (82.4%) were discharged home. Actuarial survival at 5 years was 97.2%. On comparison between group A and B, there was no significant difference in operative times, mortality, and morbidity. However, group A had shorter median length of stay (5 versus 6 days, p = 0.020) and fewer median units of red blood cell transfusion than group B (2 versus 2.5, p = 0.020). Conclusions An upper hemisternotomy approach is safe and feasible for ascending aortic and proximal arch surgical procedures, with excellent early and late outcomes. This approach is associated with shorter hospital stay and less blood transfusion.

Objective: Ventricular assist device (VAD) placement after postcardiotomy failure is associated with a high mortality. We sought to determine prognostic factors in order to help better select patients who may benefit from VAD placement. Methods: From January 1992 to January 2003, 63 patients out of approximately 30,000 cardiac surgery patients (0.21%) developed postcardiotomy failure requiring VADs. Planned VAD for bridge to transplant or bridge to recovery were excluded. Multivariate logistic regression analysis, based on pre-VAD placement parameters, was used to determine prognostic factors for in-hospital 30-day mortality. Results: Overall operative mortality was 73% (46 of 63). Multivariate logistic regression analysis identified median age ≤50 (each additional year) (OR = 0.85, 95% CI = 0.77 to 0.95, p = 0.004) and median base deficit ≥0 mEq/L (each additional mEq/L) prior to VAD placement (OR = 0.60, 95% CI = 0.48 to 0.91, p = 0.012) to be independent predictors of improved 30-day survival. Conclusions: Postcardiotomy failure is a rare event but is associated with a very poor prognosis despite salvage therapies utilizing VADs. Age ≤50 years and base deficit ≥0 (mEq/L) prior to VAD placement are associated with improved 30-day survival.

The presence of an abdominal aortic aneurysm (AAA) can be a contraindication to placement of a HeartMate left ventricular assist device (LVAD) for end-stage heart failure. We describe a 65-year-old patient who underwent endovascular repair of an AAA before placement of a LVAD as destination therapy for end-stage heart failure. This case is the first report of endovascular AAA repair before VAD placement. It not only demonstrates the utility of endovascular AAA repair in patients with undue co-morbidities, but also that the presence of an AAA should not be a contraindication to LVAD placement, if corrected.

Tatli S, Yucel EK, Couper GS, Henderson JM, Yolonda CL ystemic arterial supply to pulmonary parenchyma is a rare congenital anomaly [1]. Pulmonary sequestration is one of the most common congenital pulmonary malformations in which the involved lung parenchyma is supplied by an aberrant systemic artery [1– 5]. Rarely, an anomalous systemic artery may supply an area of otherwise normal lung, which is generally the posterobasal segment of the left lower lobe [5–8]. An aneurysm of the aberrant artery to lung is extremely rare with only three previously reported cases in the literature [9–11]. We report a case of a fusiform aneurysm of an aberrant systemic artery to the lung that arose from the distal descending thoracic aorta, supplying the posterobasal segment of the right lung, with maximal diameter of 3 cm. The diagnosis was accurately made using CT angiography using a multidetector scanner. The patient was treated successfully by right lower lobectomy and resection of the aneurysmal aberrant artery.