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Background: We report the long-term outcomes of patients who survived 20 years or greater after heart transplantation., Methods: From 1985 to 2012, 386 patients underwent heart transplantation at our institution. Patient data were analyzed retrospectively for transplants performed from 1985 to 1991. The Kaplan-Meier method was used for survival analyses., Results: In total, 133 patients were included. The mean age of the 20-year survivors at transplant was 43.6±11.4 years. The mean ischemic time was 71.2±34.0 minutes. The overall actuarial survival rates at 1, 10, and 20 years were 82.7%, 63.9%, and 55.6%, respectively. The most common causes of death were graft rejection (21%), malignancy (21%), infection (15%), and cardiac allograft vasculopathy (CAV, 14%). After 1, 10, and 20 years, the rejection-free survival rates were 19%, 13%, and 13%, respectively, and the malignancy-free survival rates were 99%, 67%, and 61%. The CAV-free survival rates were 97%, 48%, and 42%, respectively, and the infection-free survival rates were, respectively, 70%, 15%, and 14%. The actuarial diabetes-free survival rates at 1, 10, and 20 years were 85%, 80%, and 79%, respectively. Actuarial hypertension-free survival was 56% after 1 year and 26% after 10 and 20 years. Two patients received a second heart transplant., Conclusions: A remarkable number of patients survived 20 years or greater after heart transplantation, confirming the procedure as the gold standard for end-stage heart failure. Complications resulting from immunologic events and immunosuppressive therapy determine post-transplant mortality and morbidity. Due to improvements in immunosuppressive management in recent years, long-term survival is likely to increase., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Recently the Symmetry Bypass System (SJM, St. Paul, MN) became available. Now the system is frequently applied for vein-graft to aorta anastomoses in off-pump coronary artery bypass operations. This report describes a complication associated with the use of the Symmetry Bypass System (SJM) in a patient undergoing a standard off-pump coronary artery bypass procedure. A novel imaging system (SPY, Novadaq, Toronto, Canada) was applied for intraoperative assessment of graft function, and this system immediately diagnosed the occlusion of the proximal mechanical anastomosis caused by a mobile atheromatous aortic plaque.

Background: Arteriosclerotic plaques of the ascending aorta and transverse arch increase the operative risk of cardiac operations and are strong predictors for late cerebrovascular events., Methods: Twenty-two patients, mean age 68 +/- 6 years (range, 55 to 77 years), with grade IV + V plaques of the ascending aorta and transverse arch underwent coronary artery bypass grafting (n = 21) and aortic valve replacement (n = 8). Cerebrovascular emboli from unknown sources were found preoperatively in 8 patients (36%). All were in sinus rhythm. Complete thromboendarterectomy of the ascending aorta and transverse arch was performed during hypothermic circulatory arrest. After 21 +/- 12 months (range, 4 to 44 months), magnetic resonance imaging and transthoracic echocardiography of endarterectomized vessels was performed., Results: There was one perioperative death (4.5%), one early (4.5%), and one late (4.7%) adverse neurologic event. Follow-up examinations revealed normal diameters of the endarterectomized aorta., Conclusions: For patients with grade IV + V plaques, thromboendarterectomy of the ascending aorta and transverse arch can be performed with an acceptable surgical risk and a low recurrence rate for cerebrovascular events. Dilatation of the endarterectomized aorta was not observed.

Background: In acute type A dissection of the aorta, local repair with glue-aortoplasty was compared with aortic replacement., Methods: Between 1992 and 1996, 106 consecutive patients (mean age, 59 years; 84 men) were operated on average 14.5 hours after onset of dissection. A local repair (gelatin-resorcine-formaldehyde/glutaraldehyde glue, Trigon AG, Monchengladbach, Germany) without graft replacement was performed in 21 patients. Graft replacement and reinforcement of aortic stumps with gelatin-resorcine-formaldehyde/glutaraldehyde glue was performed in 85 patients (supracoronary graft, 68; aortic root replacement, 17)., Results: Survival was 79% after 30 days and 69% after 2 years. There was no difference in early mortality (p = 0.2240) and survival (p = 0.07649). Risk factors for early mortality were preoperative shock, neurologic disorder, duration of crossclamp, and extracorporeal circulation. The rate of reoperation on the proximal aorta was 31.6% (6 of 19) after local repair and 9% (6 of 64) after aortic replacement (p = 0.0157). Local repair was a significant predictor for reoperation (p = 0.0087), with decreased reoperation-free survival (p = 0.01164). In all reinterventions (four supracoronary grafts, including two valve replacements; two composite grafts; two arch replacements) breakdown of the aortoplasty was confirmed., Conclusion: Local repair has satisfactory early results but an increased incidence of reoperations due to a breakdown of the glue-aortoplasty. Indications for local repair should be restricted to high-risk patients requiring a minimal emergency surgical procedure.

A special surgical technique is required for minimally invasive coronary artery bypass grafting, particularly under beating-heart conditions. We describe a very simple system that provides improved visualization of the surgical site.

Background: Controversy exists about the choice of treatment for patients with hypertrophic obstructive cardiomyopathy. The purpose of this study was to evaluate clinical and echocardiographic long-term results in patients with hypertrophic obstructive cardiomyopathy after septal myectomy and to determine predictors of event-free survival in these patients., Methods: Between 1965 and 1995, 110 consecutive patients 2 to 66 years old (mean age, 37 +/- 15 years) with an invasively measured left ventricular outflow tract gradient of 86 +/- 39 mm Hg (81 +/- 42 mm Hg by Doppler echocardiography) underwent either septal myectomy only (n = 87) or myectomy combined with additional procedures (n = 23). Mean follow-up was 11.7 +/- 7.5 years. Predictors of late events were calculated using multivariate Cox regression analysis., Results: The perioperative mortality rate was 3.6% (n = 4). The cumulative survival rate at 5, 10, and 15 years was 93%, 80%, and 72%, respectively, and symptom-free survival, 77%, 50%, and 33%, respectively. Predictors of late death were New York Heart Association class III or IV (p < 0.05), congestive heart failure (p < 0.05) and additional procedures (p < 0.05). The left ventricular outflow tract gradient was nearly eliminated in all patients, the left atrial dimension decreased significantly during the early years, and left ventricular dilatation occurred late in 17 patients., Conclusions: Septal myectomy is associated with a low perioperative mortality and a high late survival rate (72% at 15 years' follow-up). Septal myectomy is still an excellent modality in the treatment strategy for symptomatic patients with hypertrophic obstructive cardiomyopathy.