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Right-sided infective endocarditis (RSIE) encompasses 5–10% of all infective endocarditis (IE) cases. Among them, about 90% involve the tricuspid valve (TV) (1). Major risk factors for TV infective endocarditis (TVIE) are intravenous drug use, pacemaker (PM) leads and indwelling vascular accesses (1,2). Only between 5–16% of RSIE cases require surgical intervention. Surgery for TVIE is indicated in the presence of TV vegetations >20 mm, decompensated right heart failure with severe tricuspid regurgitation (TR), recurrent pulmonary septic embolism and persistent bacteremia or sepsis due to aggressive and/or resistant microorganisms such as fungi and Staphylococcus aureus (3). Mortality of isolated TVIE is 0–15% (1). TV repair is the preferred surgical strategy; however, it is not always possible. This article presents the case of a patient with TVIE and focuses on the decision-making process and the TV operative techniques in the setting of TVIE.

Background The high risk of morbidity and mortality for patients on hemodialysis who are undergoing cardiac surgery is increased for those with active infective endocarditis (AIE). This retrospective observational single-center study evaluated the impact of chronic hemodialysis on the outcome of aortic valve replacement in patients with aortic AIE. Methods Data were retrospectively collected for consecutive patients undergoing aortic valve surgery for AIE diagnosed according to modified Duke criteria between October 1994 and January 2011. Characteristics and outcomes of patients receiving preoperative chronic hemodialysis were analyzed. Results Aortic valve AIE was present in 992 patients. Forty-five (4.5%) of the aortic valve AIE patients were receiving long-term hemodialysis preoperatively, 19 of whom (42.2%) had diabetes mellitus. Mean logistic EuroSCORE was 64.2% ± 32.2%. Twenty-four preoperative septic emboli were found in 15 patients. Results of microbiologic cultures were positive in 36 patients, with the major causative organisms identified as Staphylococcus aureus (n = 17) and Enterococcus faecalis (n = 10). Isolated aortic valve replacement was performed in 19 patients (42.2%), and 26 patients (57.8%) underwent concomitant procedures. The mean follow-up was 5.3 ± 5.2 years (range, 0.1 to 17.1 years). Postoperative complications occurred in 30 patients (66.7%). Nineteen patients (42.2%) died within 30 days of surgery, which in 8 patients was attributable to a cardiac cause. Conclusions In patients receiving chronic hemodialysis who undergo aortic valve replacement for acute AIE, postoperative mortality is high, especially in patients undergoing aortic root replacement or culture-negative AIE.

Repair of anterior mitral leaflet prolapse is one of the most challenging aspects in mitral valve repair surgery. In this review, we discuss the various techniques developed over the past three to four decades for the repair of anterior mitral leaflet prolapse, debate the pros and cons of each and compare their results, keeping reoperation for recurrent mitral regurgitation as the focal point of follow-up. At our center, chordal replacement with artificial expanded polytetrafluoroethylene sutures in the form of premeasured loops is the most commonly used technique for repair of anterior mitral leaflet prolapse for the past decade. We recommend and provide justification for the use of this technique, especially when mitral valve repair is performed through a minimally invasive approach. We believe that the trend towards a minimally invasive approach for mitral valve repair will exponentially increase in the next 5-10 years, at least until percutaneous techniques, if at all, become more reliable and safe.

Background The authors wanted to investigate whether the remodeling process in AF regarding gap junction proteins, collagen I, and amyloid may be gender dependent in humans. Methods In total, 123 patients with sinus rhythm (SR, n = 41) or atrial fibrillation (AF, n = 82) suffering from mitral valve disease undergoing cardiac surgery were included. Of the 123 patients, 66 patients (SR: n = 17, AF: n = 49) were investigated biochemically for the expression of the atrial gap junction proteins connexin40 (Cx40), connexin43 (Cx43) and collagen I and 57 patients (SR: n = 24; AF: n = 33) using histochemical methods for possible amyloid depositions. Results AF led to increased levels of Cx40, Cx43, and collagen I protein. Regarding Cx40 this upregulation was significantly higher in female than in male patients. For AF-induced changes in collagen or Cx43, there were no significant gender-dependent differences. Amyloid depositions were found with increasing age, but were not significantly related to AF or gender. Conclusions Remodeling in AF seems to be similar in men and women, with a tendency for women exhibiting somewhat stronger AF-induced changes in Cx40, which is probably a secondary effect because there is nothing known about hormone sensitivity of the Cx40 promoter, and a not significant tendency for higher Cx43 and collagen I.

ObjectivesSurgical management of tricuspid valve regurgitation mainly consists of tricuspid valve annuloplasty, usually performed with implantation of a rigid ring or a flexible band.MethodsWe performed a retrospective analysis on 820 patients who underwent tricuspid valve repair between March 2002 and July 2009 with either a flexible Cosgrove-Edwards band (n = 415; Edwards Lifesciences LLC, Irvine, Calif) or a rigid Carpentier-Edwards Classic annuloplasty ring (n = 405; Edwards Lifesciences). Mean patient age was 69.2 ± 9.5 years, 54.1% were female, and average logistic EuroSCORE was 13.3% ± 12.5%. Concomitant procedures were performed in 94.6% of patients (mitral valve surgery, 80.6%; aortic valve surgery, 28.2%; coronary artery bypass grafting, 24.5%; atrial fibrillation ablation, 44.5%). One fifth of the operations were reoperative procedures. Follow-up was 94% complete, with mean duration of 21.0 ± 19.0 months.ResultsThirty-day mortality was 10.1% (Cosgrove-Edwards, 11.9%; Carpentier-Edwards, 8.4%), and 5-year survival was 62.4% (Carpentier-Edwards, 64.7%; Cosgrove-Edwards, 60.3%). Postoperative echocardiography showed significant improvement in tricuspid valve function, with reduction in tricuspid regurgitation grade from 2.3 ± 0.7 to 0.7 ± 0.7, and no differences between groups. Use of a Carpentier-Edwards ring, however, was associated with significantly higher risk of dehiscence (Carpentier-Edwards, 8.7%; Cosgrove-Edwards, 0.9%; P

Objectives This study sought to evaluate the feasibility of minimally invasive transapical repeat valve-in-a-valve (VinV) implantation. Background Reoperative heart valve replacement for degenerated xenografts is associated with an increased surgical risk. Methods Conventional Carpentier Edwards porcine aortic (n = 5) and mitral (n = 2) valve prostheses were implanted in 7 pigs. Transapical VinV implantation of a pericardial xenograft fixed within a 23-mm stainless steel, balloon expandable stent (Cribier Edwards, Edwards Lifesciences, Irvine, California) was then performed under fluoroscopic and echocardiographic visualization on the beating heart with ventricular unloading via cardiopulmonary bypass and rapid ventricular pacing. Results Valve deployment was successfully performed in all cases. The radiopaque marking within the stent of the conventional aortic or mitral xenograft allowed for optimal positioning of the stent-delivered valve. All valves were firmly positioned without any migration. There were neither paravalvular nor transvalvular leaks, and good hemodynamic function was observed in all cases. All coronary arteries remained patent. Positioning and function were confirmed by autopsy in all animals. Conclusions The VinV concept is promising for minimally invasive beating heart repeat aortic or mitral valve replacement, using a stent-fixed sutureless prosthesis.

Aims To evaluate the feasibility of papillary muscle shortening in a specific group of high risk patients with ischaemic mitral regurgitation undergoing mitral valve reconstruction. Background From January 1996 to December 1997, 712 (10·1%) out of a total of 7042 open heart patients underwent mitral valve surgery in our hospital. Mitral valve reconstruction was performed in 408 of these patients (57·3%) and valve replacement had to be performed in 304 patients (42·7%). Methods A specific technique of papillary muscle reconstruction was performed in 32 patients undergoing valve reconstruction (7·8%). These cases had degenerated and had developed fibrotic elongated papillary muscles, which resulted in prolapses of one or more parts of the mitral valve leaflets. The aetiology in this group of patients was ischaemic, requiring concomitant myocardial revascularization in 28 patients (87·5%) with a mean of 2·7 grafts/patient. All patients underwent papillary muscle shortening using a pericardium pledget-reinforced Polytetrafluoroethylene suture and annuloplasty with a Carpentier–Edwards Physio Annuloplasty Ring. Of these 32 patients, 17 (53·1%) were male, the mean age was 67·1±9·7 years (range 41 to 81 years) and all but one were in pre-operative NYHA class III or IV. Results There were two hospital deaths (6·2%). Post-operative Doppler echocardiography indicated satisfactory mitral valve function in all patients. Within the short mean follow-up period of 9·6±5·4 months (3 to 26 months) there was one non-cardiac-related death (3·1%). There was no need for reoperation, and no cases of thromboembolic and bleeding complications in the postoperative period. All patients were in NYHA functional class I or II at the time of follow-up. Conclusion Our results indicate that mitral valve repair is a safe treatment for this group of high risk patients, and that papillary muscle shortening is a valuable tool in these patients with ischaemic mitral regurgitation undergoing surgery. The European Society of Cardiology

Knowledge regarding gender-specific mitral valve (MV) pathology and postoperative outcome is rare. We herein describe a single-center experience focusing on gender differences in MV surgery.A total of 3,761 patients underwent minimal invasive MV surgery at our institution between 1999 and 2011. Demographic data, pre-, intra-, and postoperative characteristics have been collected, including details on MV pathology and surgical technique. Patient data have been analyzed with consideration of gender-specific differences.The cohort consisted of 2,124 male (56.5%; 58.8 ± 12.5 years) and 1,637 female (43.5%; 64.5 ± 13 years) patients. Mitral regurgitation was observed equally in women (91.3%) and men (92.4%). Additional MV stenosis has been diagnosed in 2.7% of men but in 13.9% of women (p 0.001). Calcification of the posterior MV leaflet showed a similar trend: 20.1% in women compared with 6.5% in men. Prolapse of the posterior leaflet was present predominantly in men with 63.1 versus 35.7% in women (p 0.001). Distinct MV repair differences were retrospectively detected between genders: posterior mitral leaflet resection was performed in 17.9% of men versus 10.1% of women; posterior mitral leaflet chordae replacement was performed in 39.3% of men compared with 20.4% of women. Prosthetic MV replacement was necessary in 26.8% of women compared with only 10.7% of men. Concomitant tricuspid valve surgery was mostly performed in women (14.4 versus 8.2%). Male patients showed a significant better postoperative long-term survival than females, with 96, 89, and 72% compared with 92, 82, and 58% after 1, 5, and 10 years, respectively (p 0.0001).Substantial gender-specific differences regarding MV pathology, operative strategy, and long-term outcome are present that need to be addressed in clinical practice.

Background Tricuspid valve (TV) regurgitation has recently been identified as a major risk factor for long-term mortality. Isolated reoperative tricuspid valve repair/replacement (TVR/r) carries an excessively high operative risk. Currently, isolated TVR/r with minimally invasive access through a right lateral thoracotomy is being used increasingly in our institution to treat progressive TV pathologic processes after previous cardiac operations. We analyzed our early and midterm results with reoperative TVR/r in this unique patient cohort. Methods Forty-eight consecutive patients underwent isolated TV operations after previous cardiac operations with minimally invasive access through a right lateral thoracotomy at our institution between September 2000 and December 2011. Previous cardiac operations included 26 patients (54.2%) with mitral valve replacement/repair, 18 patients (37.5%) with an aortic valve replacement, 10 patients (20.4%) with a TVR/r, and 8 patients (16.7%) with coronary artery bypass grafting. Operations were performed electively in 79% of patients (n = 38). Mean patient age was 63.8 ± 13.4 years, with an average log EuroSCORE of 13.9% ± 11.3%; 67% of patients were women. Follow-up was 94% complete, with a mean duration of 2.8 ± 2.3 years. Results Thirty-day mortality for patients undergoing elective surgery was zero. For all patients early mortality was 4.2%. Five-year survival for patients after elective reoperative TVR/r through minimally invasive access was 72.2% ± 10.0%, and 5-year freedom from TV-related reoperations was 88.1% ± 6.7%, respectively. Conclusions Minimally invasive access through a right thoracotomy provides a safe option for reoperative TVR and offers excellent early outcome, particularly in elective cases. Surgical intervention should be performed earlier rather than later.

Objectives: Few studies have focused on the outcomes of tricuspid valve (TV) surgery in beating-heart technique vs. cross-clamping. Methods: Retrospective analysis of 121 patients undergoing TV surgery with isolated tricuspid valve repair or replacement in beating-heart technique (n=65) or with cross-clamp (n=56). Mean patient age was 59.3±15.9 years, 44.6% were male, and average logEuroSCORE was 11.6±11.2%. 47.9% of the operations were redos. Follow up was 98% complete with a mean duration of 30±36 months. Results: Overall thirty day mortality was 7.4%, 5-year survival was 71.0% for patients operated in beating-heart technique and 74.9% for patients operated with cross-clamp. During follow up eight patients underwent TV reoperation resulting in a 5-year event-free rate of 86.7% for patients operated in beating-heart technique and 87.7% for patients operated with cross-clamp. Conclusions: Postoperative results after TV surgery are good and comparable for patients operated in beating heart technique or with cross-clamp.

The goal of this study was to compare the outcome after mitral valve surgery through either standard sternotomy or right lateral minithoracotomy in elderly patients with higher perioperative risk.All 1,027 elderly patients (70 years) who received isolated mitral valve surgery (± tricuspid valve repair) between August 1999 and July 2009 were analyzed for outcome differences due to surgical approach using propensity score matching. The etiology of mitral valve disease was degenerative (83%), endocarditis (6%), rheumatic (10%), and acute ischemic (1%). Isolated stenosis was rare (3%); most patients had mitral valve regurgitation (72%) or combined mitral valve disease (25%).The minimally invasive approach led to longer duration of surgery (186 ± 61 vs 169 ± 59 minutes, p = 0.01), cardiopulmonary bypass time (142 ± 54 vs 102 ± 45 minutes, p = 0.0001), and cross-clamp time (74 ± 44 vs 64 ± 28 minutes, p = 0.015). There were no differences between the matched groups in 30-day mortality (7.7% vs 6.3%, p = 0.82), combined major adverse cardiac and cerebrovascular events (11.2% vs 12.6%, p = 0.86), or other postoperative outcome. Only the number of postoperative arrhythmias and pacemaker implants was higher in the sternotomy group (65.7% vs 50.3%, p = 0.023 and 18.9% vs 10.5%, p = 0.059). Long-term survival was 66% ± 5.6% vs 56 ± 5.5% at 5 years and 35% ± 12% vs 40% ± 7.9% at 8 years, and did not show significant differences.Minimally invasive mitral valve surgery through a right lateral minithoracotomy is at least as good and safe as the standard sternotomy approach in elderly patients.

Objectives: Few studies have focused on the outcomes of tricuspid valve repairs (TVR) with rigid or flexible rings in patients with tricuspid insufficiency (TI). Methods: Retrospective analysis of 820 patients undergoing TV repair with the semi-rigid Carpentier-Edwards Classic Annuloplasty Ring (CE, n=405) or the flexible Cosgrove-Edwards Annuloplasty System (COS, n=415) between March 2002 and July 2009. Mean patient age was 69.2±9.5 years, 54.1% were male, and average logEuroSCORE was 13.3±12.5%. Concomitant procedures were done in 94.6%, not excluding each other, mainly mitral valve surgery in 80.6%, aortic valve surgery in 28.2%, CABG in 24.5%, or maze-procedure in 44.5%. 21.8% of the operations were redos. Follow-up was 98% complete with a mean duration of 17.1±17months. Results: Overall thirty day mortality was 10%, 5-year survival 62%. Postoperative echo showed an improvement in TV function, from preoperative TI grade 2.31±0.66 to 0.72±0.67, with no differences in the two groups. Paravalvular leaks (PVL) were diagnosed in 8.7% (CE) vs. 0.9% (COS) of patients (p

We wanted to elucidate whether extracellular calcium may regulate the expression of the cardiac gap-junction proteins connexin 40 and connexin43. In the free wall of the left atria of 126 cardiac surgery patients with either sinus rhythm (SR) or chronic atrial fibrillation (AF), we determined the expression of the cardiac gap-junction proteins Cx43 and Cx40 by Western blot and immunohistology. For deeper investigation, we incubated cultured neonatal rat cardiomyocytes at 2 or 4 mM Ca(++) for 24 h and determined intercellular coupling, Cx40, Cx43 protein and mRNA expression, protein trafficking and sensitivity to verapamil (10-100 nM), cyclosporin A (1 microM),and BMS605401 (100 nM), a specific inhibitor of Ca(2+)-sensing receptor (CaSR). We found in patients that both Cx are up-regulated in AF in the left atrium (by 100-200%). Interestingly, Cx40 was mainly up-regulated, if total serum calcium wasor=2.2 mM, while Cx43 was independent from extracellular [Ca(++)]. In cultured cells, 4 mM Ca(++)-exposure lead to up-regulation of Cx40, but not Cx43. We found enhanced Cx40 in the plasma membrane and reduced Cx40 in the Golgi apparatus. The membrane Cx40 up-regulation resulted in enhanced gap-junction intercellular coupling with a shift in the Boltzmann fit of voltage-dependent inactivation indicating a higher contribution of Cx40 as revealed by dual whole cell voltage clamp experiments. BMS605401 could prevent all Ca(2+)-induced changes. Moreover, cyclosporin A completely abolished the Ca(2+)-induced changes, while verapamil was ineffective. We conclude that extracellular calcium (24 h exposure) seems to up-regulate Cx40 but not Cx43.

Background . Ischemic mitral regurgitation (MR), when ischemia/infarction has resulted in fibrotic degeneration and elongation of papillary muscles, carries a high risk for the patient and a technical challenge for the surgeon. We have developed a papillary-shortening plasty for this specific pathology. Methods . Papillary muscle repair was performed in 88 patients (7.2%) where degenerated and fibrotic elongated papillary muscles were found, which resulted in a prolapse of one or more parts of the mitral valve leaflets (MR III–IV). All patients had a papillary muscle-shortening plasty using a pericardium pledged-reinforced polytetrafluoroethylene suture and a ring annuloplasty. Because the cause of regurgitation in this specific group of patients was ischemic, concomitant coronary bypass grafting was required in all patients, with 2.2 grafts/patient. Results . There were five hospital deaths (5.7%). Postoperative mitral valve function was satisfactory in all patients: no residual mitral regurgitation (MR 0) was found in 80 patients (90.9%), mild regurgitation (MR I) in 5 patients (5.7%), and moderate regurgitation (MR I–II) was observed in 3 patients (3.4%). Within a short mean follow-up period of 18.6 months (3 to 40 months), there was one late death (1.2%). The actuarial freedom from reoperation and thromboembolic complications was 100%, but there were two anticoagulation-induced gastric bleeding complications (2.3%). All patients were in New York Heart Association functional class I or II at the time of follow-up. Conclusions . Our data show that careful assessment of papillary muscle pathology is mandatory, and that a papillary muscle-shortening plasty is a simple but valuable surgical tool to repair the mitral valve in this specific group of high-risk patients with ischemic mitral regurgitation.

ZusammenfassungDer Einfluß von Prednisolon, Nucleosiden und Hemmstoffen der Monoaminoxydase auf die Serotoninbindung alternder Thrombozyten wurde untersucht.Prednisolon verzögert den Aminverlust der konservierten Blutplättchen und hemmt dadurch den Abfall des Blutserotoningehalts. Nucleoside beeinflussen den Verlauf der 5-Hydroxytryptamin-Bindung nicht. Sie behindern die Sero-toninaufnahme durch die Blutplättchen im Speicherungsversuch. Unsere Versuche geben daher keinen Hinweis auf eine verbesserte biologische Überlebensdauer der Thrombozyten unter dem Einfluß dieser Stoffe.Aminoxydase-Inhibitoren hemmen den fermentativen Abbau von 5-Hydr-oxytryptamin im Plasma der Blutkonserve. Sie wirken am isolierten Organ antagonistisch gegen Serotonin und beeinflussen dadurch die biologische Bestimmung des Amingehalts der einzelnen Blutfraktionen. Die Hemmung ist in der Thrombozytenfraktion am stärksten ausgeprägt. Wir vermuten daher, daß MAO-Hemmer von Thrombozyten bevorzugt gebunden werden können. Die Bedeutung des Befundes für die Therapie mit diesen Wirkstoffen wird diskutiert.