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Background: Whether transcatheter mitral valve replacement (TMVR) devices perform similarly with respect to the underlying mitral regurgitation (MR) etiology remains unknown. The aim of the present analysis was to assess outcomes of TMVR according to the MR underlying etiology among the CHoice of OptImal transCatheter trEatment for Mitral Insufficiency (CHOICE-MI) registry., Methods: Of 746 patients, 229 patients (30.7%) underwent TMVR. The study population was subdivided according to primary, secondary, or mixed MR. Patients with mitral annular calcification were excluded. The primary study endpoint was a composite endpoint of all-cause mortality or hospitalization for heart failure at 1 year. Secondary study endpoints were all-cause and cardiovascular mortality at 1 year, New York Heart Association functional class, and residual MR, both at discharge and 1 year., Results: The predominant MR etiology was secondary MR (58.4%), followed by primary MR (28.7%) and mixed MR (12.9%). Technical success and procedural mortality were similar according to MR etiology. Discharge echocardiography revealed residual MR 2+ in 11.3%, 3.7%, and 5.3% of patients with primary, secondary, and mixed MR, respectively (P = .1). MR elimination was similar in all groups up to the 1-year follow-up. There was no difference in terms of primary combined outcome occurrence according to MR etiology. One-year all-cause mortality was reported in 28.8%, 24.2%, and 32.1% of patients with primary, secondary, and mixed MR, respectively (P = .07)., Conclusions: In our study we did not find differences in short-term and 1-year outcomes after TMVR according to MR etiology., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Aortic valve (AV) repair is an evolving surgical strategy in the treatment of nonelderly adults with aortic regurgitation. We aimed to determine the 1-year outcome after AV repair vs surgical AV replacement (sAVR) using real-world data from the German Aortic Valve Registry., Methods: A total of 8076 aortic regurgitation patients (mean age, 59.1 ± 15.0 years; 76% men; mean The Society of Thoracic Surgeons score, 1.3 ± 1.1), who underwent AV surgical procedures between 2011 and 2015, were identified from German Aortic Valve Registry. The AV was repaired in 2327 patients (29%), and the remaining 5749 patients (71%) underwent sAVR. A weighted propensity score model, including the variables of age, sex, and The Society of Thoracic Surgeons score, was used to correct for baseline differences between AV repair and sAVR cohorts. The primary end point was 1-year survival after AV repair vs sAVR. Secondary end points were freedom from cardiac events and AV reinterventions., Results: Survival at 1 year was 97.7% (95% CI, 97.0%-98.5%) in the AV repair cohort vs 96.4% (95% CI, 95.9%-96.9%) in the propensity score-weighted sAVR cohort (log-rank P < .001). Cox regression revealed a significant advantage of AV repair vs sAVR (hazard ratio, 0.68; 95% CI, 0.51-0.90; P < .0001) on 1-year survival, which was independent of age. Cardiac event-free survival at 1 year was 85.7% (95% CI, 483.8%-87.7%) in the AV repair group vs 81.7% (95% CI, 80.7%-82.9%) in the sAVR group (log-rank P < .001). AV reintervention was required in 38 AV repair patients (1.6%) compared with 1.6% in the sAVR cohort (P = .59)., Conclusions: AV repair surgery, whenever intraoperatively feasible, is associated with a significantly better 1-year survival and 1-year cardiac event-free survival compared with sAVR., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Implantation of hybrid prostheses using the frozen elephant trunk technique has become a standard procedure for aortic arch and proximal descending aorta pathologies. New devices have been introduced to reduce surgical complexity by enabling the frozen elephant trunk technique to be performed in proximal segments of the aorta. This facilitates a minimally invasive approach and provides a safe and durable aortic arch repair. We herein report on the first human experience with the new trifurcated frozen elephant trunk aortic prosthesis, E-vita OPEN NEO (CryoLife/JOTEC GmbH, Hechingen, Germany), using a minimally invasive technique., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Comprehensive information on the characteristics of surgical heart valves (SHVs) is essential for optimal valve selection. Such information is also important in assessing SHV function after valve replacement. Despite the existing regulatory framework for SHV sizing and labelling, this information is challenging to obtain in a uniform manner for various SHVs. To ensure that clinicians are adequately informed, the European Association for Cardio-Thoracic Surgery (EACTS), The Society of Thoracic Surgeons (STS) and American Association for Thoracic Surgery (AATS) set up a Task Force comprised of cardiac surgeons, cardiologists, engineers, regulatory bodies, representatives of the International Organization for Standardization and major valve manufacturers. Previously, the EACTS-STS-AATS Valve Labelling Task Force identified the most important problems around SHV sizing and labelling. This Expert Consensus Document formulates recommendations for providing SHV physical dimensions, intended implant position and hemodynamic performance in a transparent, uniform manner. Furthermore, the Task Force advocates for the introduction and use of a standardized chart to assess the probability of prosthesis-patient mismatch and calls valve manufacturers to provide essential information required for SHV choice on standardized Valve Charts, uniformly for all SHV models., (Copyright © 2021 Jointly between The Society of Thoracic Surgeons, the American Association for Thoracic Surgery, and the European Association for Cardio-Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Hemodynamic performance of the Avalus valve through 3 years after implant is comparable to that of contemporary surgical bioprostheses. Many variables affect hemodynamic outcomes, including surgical technique. This article describes our experience with the Avalus bioprosthesis and strategies to achieve optimal hemodynamic performance., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Approximately 5% of percutaneous pulmonary valve implantations (PPVIs) are at risk for coronary compression. Therefore, PPVI is contraindicated if coronary anomalies and tested coronary flow impairment are observed. Simultaneous right ventricular outflow tract ballooning and coronary angiography are mandatory elucidating contraindications for PPVI. We present the case of a 22-year-old woman who had Rastelli repair with chronic right heart failure. Weighing the risk of several offered surgical options, she underwent successful PPVI after minimally invasive direct coronary artery bypass procedure., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Various devices are available for endoscopic radial artery harvesting during coronary artery bypass grafting. Thermal spread and graft damage, however, are common concerns. The aim of this study was to compare the MiFusion TLS2 system (Endotrust, Nettetal Germany) with direct heat technique and the LigaSure Maryland system (Medtronic, Dublin, Ireland) using advanced bipolar technique in a prospective randomized study., Methods: One hundred consecutive patients undergoing coronary artery bypass grafting with endoscopic radial artery harvesting were prospectively included and randomized 1:1. The proximal (brachial) ends of the grafts were analyzed using fluorescence microscopy with focus on graft integrity. In addition, harvesting time, graft sealing, residual bleeding, and incidence of neurological disorders were compared., Results: Patient age was 67 ± 8 years. Mean harvesting time was 26.5 ± 9 minutes for the TLS2 and 23.2 ± 8 minutes for the LigaSure (P = .049). Overall graft integrity was good in both groups. A significantly better graft integrity was observed in the LigaSure group (scale 0 to 3; 3 = best) with 2.5 ± 0.6 for TLS2 and 2.8 ± 0.4 for LigaSure (P = .031). LigaSure provided significantly better graft sealing (scale 0 to 2; 0 = best) with 0.6 ± 0.7 vs 1.0 ± 0.6 (TLS2) (P = .006) and less residual bleeding (scale 1 to 5; 1 = best) with 1.4 ± 0.6 vs 2.0 ± 0.9 (TLS2) (P < .001). Transient sensibility disorders were less frequently observed with LigaSure (2% vs 16%, P = .015)., Conclusions: Endoscopic radial artery harvesting can be performed with excellent results and good graft integrity using both devices. Compared with the MiFusion TLS2, the LigaSure device led to faster procedural times and resulted in better graft integrity. Along with providing a better seal, LigaSure was associated with less sensibility disorders., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Intraoperative surgical prosthetic heart valve (SHV) choice is a key determinant of successful surgery and positive postoperative outcomes. Currently, many controversies exist around the sizing and labelling of SHVs rendering the comparison of different valves difficult. To explore solutions, an expert Valve Labelling Task Force was jointly initiated by the European Association for Cardio-Thoracic Surgery (EACTS), The Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS). The EACTS-STS-AATS Valve Labelling Task Force, comprising cardiac surgeons, cardiologists, engineers, regulators and representatives from the International Organization for Standardization (ISO) and major valve manufacturers, held its first in-person meeting in February 2018 in Paris, France. This article was derived from the meeting's discussions. The Task Force identified the following areas for improvement and clarification: reporting of physical dimensions and characteristics of SHVs determining and labelling of SHV size, in vivo and in vitro testing and reporting of SHV hemodynamic performance and thrombogenicity. Furthermore, a thorough understanding of the regulatory background and the role of the applicable ISO standards, together with close cooperation between all stakeholders (including regulatory and standard-setting bodies), is necessary to improve the current situation. Cardiac surgeons should be provided with appropriate information to allow for optimal SHV choice. This first article from the EACTS-STS-AATS Valve Labelling Task Force summarizes the background of SHV sizing and labelling and identifies the most important elements where further standardization is necessary., (Copyright © 2019 The Society of Thoracic Surgeons, The American Association for Thoracic Surgery, and the European Association for Cardio-Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Transcatheter aortic valve implantation (TAVI) has been established as a therapeutic option in patients with a high procedural risk presenting with severe aortic stenosis. Recent improvements of TAVI technology made it possible to treat degenerated bioprosthesis using the valve-in-valve implantation concept. The self-expanding CoreValve (Medtronic, Minneapolis, MN) prosthesis has recently been redesigned and was introduced into clinical practice. We report a case of a not fully expanded Medtronic CoreValve Evolut R after deploying a 26 mm prosthesis into a degenerated 25 mm Carpentier-Edwards Perimount prosthesis., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Conventional aortic valve replacement (AVR) remains the therapy of choice for many patients with severe aortic valve disease. The unique German Aortic Valve Registry (GARY) allows the comparison of contemporary outcomes of AVR with those of transcatheter AVRs. We report here real-world, all-comers outcomes of AVR, including combined AVR and coronary bypass grafting (AVR+CABG)., Methods: A total of 34,063 patients who received AVR (22,107 patients, 39% female; mean age 68.0 ± 11.3 years, mean logistic European System for Cardiac Operative Risk Evaluation, 8.6%) or AVR+CABG (11,956 patients, 28% female; mean age 72.6 ± 7.8 years, mean logistic European System for Cardiac Operative Risk Evaluation, 10.7%) between 2011 and 2013 were analyzed and followed up to assess the 1-year outcome., Results: In-hospital mortality was 2.3% for AVR and 4.1% for AVR+CABG. Other important outcome variables include stroke (AVR, 1.2%; AVR+CABG, 1.9%) and new pacemaker implantation (AVR, 4.4%; AVR+CABG, 3.6%). Survival at 1 year was 93.2% for AVR and 89.4% for AVR+CABG. Total stroke rates at 1 year were 1.6% for AVR and 2.0% AVR+CABG. Quality of life assessment indicated that most patients were in New York Heart Association Functional Classification I or II (AVR, 86%; AVR+CABG, 84%) and that they were satisfied with the overall postoperative course (AVR, 88%; AVR+CABG, 87%)., Conclusions: Contemporary surgical AVR yields excellent outcomes with low in-hospital mortality, a low overall complication rate, and good 1-year outcome for all risk groups. Accordingly, conventional AVR remains an important therapeutic option for many patients., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: In the present report we describe our clinical experience using specific image-based decision making and anatomic considerations for transcatheter valve-in-valve (ViV) implantation in degenerated xenografts with their pericardial leaflets externally mounted around the stent (Mitroflow [SORIN Group, Milan, Italy] or Trifecta [St. Jude Medical, St Paul, MN]). This design seems to increase the risk of coronary ostia obstruction after ViV procedures., Description: We report 5 patients with degenerated Mitroflow or Trifecta xenografts in whom different anatomic considerations led to different treatment strategies., Evaluation: One patient underwent conventional redo aortic valve replacement, 2 patients underwent transcatheter ViV implantation with first-generation prostheses, and 2 patients underwent transcatheter ViV implantation using the Engager prosthesis (Medtronic, Minneapolis, MN). All patients were discharged alive in good clinical condition and were alive at 30 days after the procedure., Conclusions: Transcatheter ViV procedures can be performed safely in degenerated Mitroflow and Trifecta prostheses, if the anatomy of the aortic root is taken into consideration. Precise preoperative image-based decision making is mandatory. The Engager prosthesis may allow for ViV procedures even in patients with smaller aortic roots., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Transapical aortic valve implantation (TA-AVI) has evolved as a treatment option for high-risk patients who have severe aortic stenosis. The aim of this study was to evaluate the feasibility of a novel apical closure device to allow for standardized apical access and closure., Description: The Apica ASC system consists of three components: an introducer system, a left ventricular low-profile titanium coil, and a closure cap. The ASC introducer system is fixed to the myocardium by anchoring the titanium coil into the epicardium. After the TA-AVI procedure, the closure cap is introduced through the system and delivered onto the titanium coil for final sealing., Evaluation: After sternotomy, fixation of the introducer system was successfully performed in an acute pig model. The apex was safely secured in all attempts, and the titanium coil created an effective seal around the Ascendra sheath. Finally, the closure cap was shown to be secure even when the hearts were pressurized to 200 mm Hg. Postmortem examination showed a uniform depth of the titanium coil through the endocardium into the myocardial wall without penetration into the left ventricular cavity., Conclusions: Apical access and closure is feasible using the sutureless Apica ASC device. The system seems to have the potential to further standardize the TA-AVI procedure, allowing wider applicability and more generalizability., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patient selection for transcatheter aortic valve implantation (TAVI) remains highly controversial. Some screened patients subsequently undergo conventional aortic valve replacement (AVR) because they are unsuitable TAVI candidates. This study examined the indications and outcomes for these patients, thereby determining the efficacy of the screening process., Methods: Between January 2006 and December 2010, 79 consecutive patients (49% men), aged older than 75 years with high surgical risk, were screened for TAVI, but subsequently underwent conventional AVR through a partial or complete sternotomy. The indications, demographics, and outcomes of this cohort were studied., Results: Mean age was 80.4±3.6 years. Mean left ventricular ejection fraction was 0.55±0.16, and the mean logistic European System for Cardiac Operative Risk Evaluation was 13%±7%. Of the 79 patients, 6 (7.6%) had prior cardiac surgical procedures. Indications for TAVI denial after patient evaluations were a large annulus in 31 (39%), acceptable risk profile for AVR in 24 (30%), need for urgent operation in 11 (14%), and concomitant cardiovascular pathology in 5 (6%). Mean cross-clamp time was 55±14 minutes, and cardiopulmonary bypass time was 81±21 minutes. Concomitant procedures included a Maze in 12 patients (15%). Postoperative morbidity included permanent stroke in 2 (2.5%), respiratory failure in 9 (11%), and pacemaker implantation in 2 (2.5%). Hospital mortality was 1.3% (1 of 79). Cumulative survival at 6, 12, and 36 months was 88.5%, 87.1% and 72.7%, respectively., Conclusions: Our existing patient evaluation process accurately defines an acceptable risk cohort for conventional AVR. The late mortality rate reflects the advanced age and comorbidities of this cohort. The data suggest that overzealous widening of TAVI inclusion criteria may be inappropriate., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Transcatheter aortic valve implantation has gained widespread acceptance to treat elderly high-risk patients with aortic stenosis. We used a subcutaneous rat model to evaluate whether crimping may affect valve long-term durability., Methods: Standard Sapien transcatheter valves (Edwards Lifesciences, Irvine, CA) were crimped for different durations (1 hour, 1 day, 1 month) and uncrimped, and leaflet pieces as well as control tissue (Perimount Magna, Edwards) were then implanted subcutaneously in 15 male weanling Sprague-Dawley rats for 12 weeks. Grade of calcification was measured by freeze-dried mass and van Kossa staining. Histologic and electron microscopic examination were performed to investigate potential leaflet-fragmentation caused by crimping., Results: There were no differences in calcification among the groups. The calcium carbonate concentrations in all samples ranged from 0.1 to 100 mg/g dry weight. Leaflet morphology, however, differed from no fragmentation (control group) to highly fragmented tissue (1-month crimped). These differences reached statistical significance between crimped and non-crimped leaflets (p<0.003)., Conclusions: Transcatheter valve crimping does not necessarily affect leaflet calcification. However, the structural changes of the leaflets that were caused by crimping may have clinical significance. Duration of crimping should be as short as possible, and very tight crimping to small diameters should be avoided., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patients with impaired left ventricular ejection fraction (LVEF) and severe aortic stenosis have a higher perioperative risk for aortic valve replacement. Transapical aortic valve implantation (TA-AVI) allows for off-pump valve implantation, which might be beneficial in the subgroup of patients with impaired LVEF., Methods: All patients with LVEF≤40% who underwent TA-AVI for severe aortic stenosis and who fulfilled at least 1-year follow-up formed the study group. Results were compared to TA-AVI patients with preserved LVEF treated during the same time period., Results: Thirty-nine patients with LVEF≤40% were identified, mean LVEF was 32.5±7.1%. Logistic EuroSCORE and STS-score were 43.6%±18.5% and 15.3%±9.3%, respectively. Concomitant coronary artery disease was present in 59% with 23.1% having had previous bypass surgery and 17.9% having had a history of prior myocardial infarction. Two patients required cardiopulmonary-bypass support due to intraoperative complications, and another 2 patients required cardiopulmonary-bypass for reperfusion. Median procedure time was 75 minutes (interquartile range, 65-90 minutes). LVEF at discharge increased significantly to a mean of 41.5%±10%, and at 1-year follow-up to 53.9%±13% (both p<0.0001). The proportion of patients in New York Heart Association class III-IV decreased from 92.3% to 15.0% at 1-year follow-up (p<0.001). There was neither a statistically significant difference in in-hospital mortality nor in long-term survival up to 4 years, in comparison to patients with preserved LVEF., Conclusions: Transapical aortic valve implantation is a promising approach, allowing for off-pump treatment of elderly, high-risk patients with impaired LVEF requiring aortic valve replacement. Short-term and long-term outcomes are respectable, and an improvement in postoperative LVEF and New York Heart Association class can be anticipated., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Repeat aortic valve surgery (rAVS) is usually associated with an increased risk profile due to advanced patient age and comorbidities. We analyzed the current early and late results for isolated rAVS., Methods: One hundred fifty-five patients underwent isolated rAVS from November 1994 to April 2008, of which, 86 received isolated redo aortic valve surgery (rAVS without root) and 69 received aortic root replacement (rAVS with root) as the second operation., Results: Patient age was 58 ± 16 years; 23% were female. The indications for redo surgery were infective endocarditis (27.1%, n = 42), bioprosthetic structural valve dysfunction and degeneration (23.8%, n = 37), mechanical valve nonstructural dysfunction (7.2%, n = 11), paravalvular leak (18.1%, n = 28), aortic dissection (2.6%, n = 4), and aortic aneurysm (7.1%, n = 11). Early mortality was 4.5% (n = 7) for all patients (3.5% for rAVS without root and 5.8% for rAVS with root, p = 0.5). Left ventricular ejection fraction less than 0.30 (odds ratio 9.2, 95% confidence interval [CI] 1.1 to 80.3) and preoperative neurologic dysfunction (odds ratio 22.1, 95% CI 2.3 to 197.4) were found to be the independent predictors for in-hospital mortality according to multivariate analysis. Follow-up was 100% complete with a mean duration of 2.7 ± 2.8 years for all patients. Five-year and eight-year survival was 66% ± 5% and 61% ± 6% for all patients and did not significantly differ between surgical groups. Cox regression analysis revealed the following independent predictors of long-term survival: preoperative New York Heart Association functional class IV (hazard ratio 2.2, 95% CI 1.5 to 3.2, p < 0.01) and infective endocarditis (hazard ratio 2.2, 95% CI 1.4 to 3.1, p < 0.01)., Conclusions: Repeat isolated aortic valve surgery is associated with respectable outcomes. Follow-up results reveal good long-term survival for this group., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Conventional aortic valve replacement can be technically challenging in patients with porcelain aorta and is associated with a high rate of stroke and mortality. Porcelain aorta is even sometimes seen as contraindication for surgery. Minimally invasive off-pump transapical aortic valve implantation may be an optimal strategy to treat elderly patients with porcelain aorta requiring aortic valve replacement., Methods: Twenty-nine patients with severe aortic stenosis and porcelain aorta underwent transapical aortic valve implantation. Mean age was 79 ± 7.8 years (range, 64 to 93 years), with 65.5% female. Logistic EuroSCORE and the Society of Thoracic Surgeons score were 37.7% ± 18.1% and 12.8% ± 2.2%, respectively. Peripheral vascular disease (41.4%) and carotid artery stenosis (58.6%) were frequent, and 17.2% of patients had experienced a stroke previously. The majority of patients were redo cases (51.2%), and 10.3% were dependent on chronic hemodialysis. In 13.8% of all patients, intraoperatively detected porcelain aorta caused an attempt at conventional aortic valve replacement by means of sternotomy to be aborted., Results: All valves were implanted successfully without embolization or aortic dissection. All procedures were primarily performed off-pump, but 4 patients required secondary cardiopulmonary bypass as a result of complications. Median procedure time was 80 minutes, and median intensive care unit stay was 1 day. Stroke occurred in 1 patient only. Thirty-day mortality was 17.2%. Mild paravalvular leak was seen in 31.0%, and mild to moderate regurgitation occurred in 1 patient., Conclusions: Transapical aortic valve implantation is a promising approach to treat elderly patients with porcelain aorta requiring aortic valve replacement. It is associated with acceptable outcome and low stroke rates., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The reoperative risk for degenerated aortic valve xenografts may be increased in elderly patients with comorbidities. We evaluated the off-pump beating heart concept of transapical aortic valve implantation using the valve-in-valve (VinV) concept., Methods: Since March 2007, 11 patients with degenerated xenografts received transapical aortic valve implantation using the Edwards Sapien transcatheter heart valve (Edwards Lifesciences, Irvine, CA). After informed consent, all procedures were performed as an off-label use. Mean patient age was 78 +/- 6 years (range, 72 to 89), mean logistic European System for Cardiac Operative Risk Evaluation was 32% +/- 16% (range, 16% to 62%) and mean Society for Thoracic Surgeons score was 7% +/- 3% (range, 3% to 10%)., Results: All patients were treated off pump. The transapical aortic valve implantation was successful in all patients, and apical access was uncomplicated in all of them. Total operating room time was 71 +/- 14 minutes. On postoperative echocardiography, there was no paravalvular incompetence in any and mild (first degree) central incompetence in 2 of 11 patients. Sufficient flaring of the inflow and outflow parts of the Sapien prosthesis was observed in all patients, suggesting a stable position and an almost absent risk of late embolization. Maximal transvalvular pressure gradients were 21 +/- 8 mm Hg, and mean echocardiographic pressure gradients were 11 +/- 4 mm Hg. Follow-up extends to 330 +/- 293 days (range, 15 to 1,007), and all patients are well and alive., Conclusions: Valve-in-valve implantation is a truly minimally invasive procedure for redo treatment of failed aortic valve xenografts in high-risk elderly patients. The Edwards Sapien valve is well suited for VinV implantation, and this technique may become a routine procedure to treat degenerated xenografts in the future., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Chronic total occlusion (CTO) of coronary vessels is still a challenge for percutaneous coronary intervention and recent data show unfavorable long-term results compared with medical therapy. It is unclear whether CTO is also a negative predictor for long-term outcome in minimally invasive bypass grafting., Methods: From 1996 to 2007 minimally invasive surgical revascularization of the left internal mammary artery to the left anterior descending artery (LAD) was performed in 1,800 patients. Demographic data, risk factors, perioperative outcome, and annual follow-up were obtained from all patients. Estimated survival and freedom from major adverse cardiac and cerebrovascular events or recurrence of angina with log-rank tests and Cox regression analysis for identification of independent risk factors were calculated for patients with (420 patients) and without (1,380 patients) CTO of the LAD., Results: Revascularization of the LAD could be completed in all but one patient (99.8% success rate with CTO). At 5 years estimated overall survival was 90.5% (95% confidence interval [CI] 85.8 to 95.5) with CTO and 90.4% (95% CI 85.8 to 95.1) without CTO (p = 0.91). Freedom from major adverse cardiac and cerebrovascular events and angina with or without CTO at 5 years was 83.2% (95% CI 77.6 to 88.8) and 85.5% (95% CI 82.6 to 88.1), respectively (p = 0.64). Chronic occlusion of the target vessel and other preoperative factors were not identified as risk factors for major adverse cardiac and cerebrovascular events during follow-up., Conclusions: As opposed to percutaneous coronary intervention, minimally invasive bypass grafting of a totally occluded LAD is almost always possible and chronic occlusion is not a negative predictor for short and long-term outcome. Minimally invasive bypass grafting of the LAD should be considered the treatment of choice for chronically occluded left anterior descending arteries., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Surgical management of patients with complete atrioventricular septal defect (AVSD) has advanced over the last decades. Definitive early surgical repair for AVSD has become the treatment of choice at many centers. This trend has contributed to the recent decline in postoperative mortality and good long-term results., Methods: We reviewed long-term results of 100 consecutive patients with complete AVSD undergoing definitive early repair with a two-patch technique and complete cleft closure operated on between June 1999 and June 2009. Valve performance, mortality, morbidity, and indications for reoperation were retrospectively studied., Results: Median age at operation was 3.8 months (range, 15 days to 4.7 years); median weight was 5.0 kg (range, 3.0 to 19 kg). Follow-up was 99% complete (mean 58 months; range, 1 to 120 months). Early definitive repair was performed in all patients who initially presented to our institution over the study period. There was no perioperative, in-hospital mortality, or late mortality. At the latest follow up, left atrioventricular valve (LAVV) regurgitation was absent or trace in 80 patients (80%), mild to moderate in 15 patients (15%), and moderate to severe in 4 patients (4%). Right AV valve regurgitation was none or trace in 86 patients (86%), mild to moderate in 11 patients (11%), and moderate to severe in 2 patients (2%). Actuarial freedom from reoperation for LAVV dysfunction at 1, 3, 5, and 10 years was 98%, 95%, 94%, and 94%, respectively. Actuarial freedom from reoperation for left ventricular outflow tract obstruction at 1, 3, 5, and 10 years was 100%, 99%, and remained constant by 99% at 5 and 10 years., Conclusions: Definitive early repair for complete AVSD can be performed with excellent results. The two-patch technique with complete cleft closure is a safe and reproducible surgical method that can achieve very low mortality and stable long-term outcomes, even in neonates., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: It is unknown whether patients undergoing valve surgery benefit from preoperative statin therapy. We examined the effects of statin treatment in a large group of patients undergoing valve surgery., Methods: Between October 2001 and May 2008, a total of 10,061 patients underwent isolated or combined valve surgery at our institution. Patients were divided into those who received preoperative statin therapy (group 1, n = 4,216) versus those who did not receive statin therapy (group 2, n = 5,538). Patients in whom preoperative statin therapy status was unknown (n = 307) were excluded. Follow-up survival information was available in all patients., Results: Group 1 patients had more comorbidities, were more likely to undergo concomitant coronary artery bypass grafting (46.0% versus 20.7%; p < 0.001), and had a higher mean EuroSCORE predicted risk of mortality (12.4% +/- 13.5% versus 11.5% +/- 13.9%; p = 0.002). Patients receiving preoperative statin therapy had a higher incidence of low cardiac output syndrome (8.4% versus 6.0%; p < 0.001) and the combined cardiac outcome of myocardial infarction, low cardiac output syndrome, and 30-day mortality (11.8% versus 9.6%; p < 0.001) by univariate analysis. Multivariable analyses, however, revealed no significant effect of statin therapy on perioperative cardiac outcomes. Cox multivariable regression revealed no significant effect of statin therapy on long-term survival in the entire patient cohort, but statin therapy was associated with a long-term survival benefit (hazard ratio, 0.81; 95% confidence interval, 0.70 to 0.93; p = 0.003) in patients who underwent concomitant coronary artery bypass grafting., Conclusions: Our large series failed to detect a protective effect of preoperative statin therapy on perioperative outcomes or long-term survival in patients undergoing isolated valve surgery. Valve patients undergoing concomitant coronary artery bypass grafting, however, appear to receive a long-term survival benefit from statins., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Mechanical strain may affect aortic valve cusp, leading to an altered extracellular matrix ultrastructure and eventually aortic stenosis. The aim of this study was to evaluate the affect of these potential relationships on human tissue., Methods: Extracellular matrix protein disposition was analyzed on human aortic valve cusp retrieved from 31 patients during routine aortic valve replacement surgery. Samples were immediately fixed in 2-hydroxyethyl methacrylate. Immunohistology and Western blot analysis were used to quantify decorin, tenascin-C, biglycan, alkaline-phosphatase, osteocalcin, and osteopontin content. Fibroblast function was analyzed on interstitial cells derived from aortic valve cups from patients undergoing aortic valve replacement. Cells were grown to confluency in modified Eagle's medium supplemented with 10% fetal calf serum under sterile conditions. Thereafter, mechanical strain was applied for 72 hours and 60 cycles per minute. Elongation of as much as 10% in comparison with no elongation (control group) was applied. All results were correlated to hemodynamic variables., Results: Decorin and biglycan were mostly located at the inflow aspects of the cusp, tenascin-C in the central layer, and osteopontin, osteocalcin, and alkaline phosphatase were concentrated near the cell populations surrounding calcified areas. The intensity of this protein expression was significantly related to the pressure gradient. Expression levels were twice to five times higher than normal in patients with a preoperative pressure gradient of more than 100 mm Hg. On fibroblasts subjected to mechanical strain, a similar significant increase in the expression for decorin, biglycan, alkaline-phosphatase, tenascin-C, osteocalcin, and osteopontin was found by immunohistology. Western blot analysis confirmed significantly enhanced expressions of two and eight times the normal levels., Conclusions: A specific pattern of extracellular matrix protein expression was found in relation to mechanical strain on human aortic valve cusp tissue and in mechanically stimulated human valvular fibroblasts. This new insight into the process of aortic valve degeneration may be important for further therapeutic approaches to ameliorate the progression or even the initiation of potential aortic valve stenosis.

Transapical aortic valve implantation is a minimally invasive, beating-heart procedure that normally requires a general anesthetic. We herein report an 85-year-old patient with impaired pulmonary function who underwent successful transapical aortic valve implantation while awake, using a thoracic epidural anesthetic.

Background: The Toronto Root bioprosthesis with BiLinx anticalcification treatment (St. Jude Medical, St. Paul, MN) was introduced into clinical practice in 2001, mainly for patients with aortic valve disease and additional pathology of the aorta. Patients included in the initial clinical study with core laboratory data evaluation were reviewed., Methods: A total of 186 patients (62 +/- 11 years, 38 female) received full root replacement at our institution with the Toronto Root bioprosthesis from June 2001 until November 2007. The predominant aortic valve lesion was stenosis in 34, incompetence in 80, and mixed lesions in 72 patients. Additional procedures included replacement of the ascending aorta in 139, replacement of the ascending aorta plus aortic arch in 38, coronary artery bypass graft surgery in 31, mitral valve repair in 26, atrial fibrillation ablation in 14, and atrial septal defect closure in 8 patients. Previous cardiac surgery had been performed in 10 patients. Mean follow-up was 50 +/- 26 months (770 patient-years)., Results: The mean implanted valve size was 26.8 +/- 1.8 mm (14 x 23 mm, 36 x 25 mm, 87 x 27 mm, and 48 x 29 mm). Aortic cross-clamp time was 99.8 +/- 29 minutes, and cardiopulmonary bypass time was 140.9 +/- 52 minutes. All patients showed a clinical improvement of at least one New York Heart Association class during follow-up. Most recent echocardiographic examination revealed a maximum transvalvular blood flow velocity of 2.1 +/- 0.5 m/s and a mean pressure gradient of 9.6 +/- 8.5 mm Hg. Left ventricular ejection fraction was 61% +/- 11%. Early mortality was 5.9% +/- 1.7%, and 5-year survival was 83.3% +/- 3.0%. Patients who underwent isolated aortic root surgery had a 5-year survival of 90.3% +/- 4.2%., Conclusions: The Toronto Root bioprosthesis is safe and provides good clinical and hemodynamic function after full root replacement with or without additional aortic surgery. Owing to the specific anticalcification treatment, long-term durability may be promising.

Background: Mitral valve (MV) repair for posterior mitral leaflet (PML) prolapse has proven excellent results. The loop technique, which involves insertion of polytetrafluoroethylene neochordae while preserving the native PML tissue, was developed to facilitate MV repair through a minimally invasive approach. The aim of this study was to assess the medium-term results of the loop technique in comparison with the widely adopted leaflet resection technique for repair of isolated PML prolapse., Methods: Between March 1999 and January 2008, a total of 1,708 patients underwent minimally invasive MV repair. Six hundred and seventy patients (39.2%) had isolated PML prolapse and were treated with either the loop technique (n = 317) or the leaflet resection (n = 353) technique, according to surgeon preference. Mean follow-up time was 2.8 +/- 2.2 years, and follow-up was 99% complete., Results: Early postoperative echocardiography showed a significantly larger mitral orifice area (3.3 +/- 0.3 cm(2) versus 3.0 +/- 0.8 cm(2), p < 0.001) and lower mean pressure gradient (2.7 +/- 1.7 mm Hg versus 3.1 +/- 1.7 mm Hg, p = 0.03) after implantation of loops. Other perioperative outcomes were similar for the two groups of patients. Freedom from reoperation at 5 years was significantly higher after the loop technique (98.7%, 95% confidence interval [CI]: 96.7% to 99.5%) when compared with leaflet resection (93.9%, 95% CI: 90.7% to 96.1%, log-rank p = 0.005). Cox regression analysis revealed that implantation of a flexible, incomplete band was an independent predictor of reoperation (hazard ratio 6.2, 95% CI: 1.3 to 110.7), whereas use of leaflet resection had a nonsignificant trend toward an increased reoperation rate (hazard ratio 2.6, 95% CI: 0.9 to 9.1). Reoperation for excessive systolic anterior motion did not occur in any loop patient., Conclusions: Both the loop technique and conventional leaflet resection yield excellent results for repair of isolated PML prolapse. The technical ease of performing the loop technique through a minimally invasive approach, however, makes this method a particularly valuable alternative for MV repair surgery.

Background: With the advent of percutaneous valve implantation, an increasing amount of interest is being expressed in outcomes of conventional aortic valve replacement (AVR) in elderly patients. We evaluated characteristics and outcomes of elderly patients undergoing isolated AVR with a particular focus on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification., Methods: All patients aged 80 years or older (n = 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES(log)) risk stratification. Surgical risk was defined as low risk (ES(log) < or = 10% [n = 107]), moderate risk (10% < ES(log) < 20% [n = 103]), and high risk (ES(log) > or = 20% [n = 72]). Patient age was 82 +/- 2 years (low risk), 82.7 +/- 2.7 years (moderate risk), and 83.6 +/- 3.1 years (high risk), respectively (p < 0.05). Mean ES(log) predicted risk of mortality was 7.3% +/- 1.4% (low risk), 13.7% +/- 2.5% (moderate risk), and 33.0% +/- 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete., Results: In-hospital mortality was 7.5% (low risk), 12.6% (moderate risk), and 12.5% (high risk; p = 0.4). One-year survival was 90%, 78%, and 69% (p = 0.002); 5-year survival was 70%, 53%, and 38% (p = 0.05); and 8-year survival was 38%, 33%, and 21% (p = 0.017), for low-, moderate-, and high-risk patients, respectively. Independent predictors for in-hospital mortality were pulmonary hypertension and urgent indication for surgery. Cox regression predictors of medium-term survival were congestive heart failure, urgent timing, previous stroke or transient ischemic attack, and EuroSCORE stratum., Conclusions: Aortic valve replacement can be performed in the elderly population with acceptable outcomes. EuroSCORE risk stratification is imprecise for prediction of perioperative mortality among octogenarian AVR patients, but may be useful for predicting mortality during medium-term follow-up.

Transapical aortic valve implantation has become a routine procedure to treat high-risk patients in some centers. To facilitate optimal positioning, a new self-centering valve design with anatomic orientation of the commissures has been developed. This self-expanding nitinol stent-based valve has 3 support arms that are placed within the aortic sinuses. Here we report implantation of this new valve in a patient. The valve demonstrated excellent function with a low transvalvular gradient.

Objective: This study evaluated the results for minimally invasive mitral valve (MV) surgery in patients who had undergone previous cardiac operations through a sternotomy., Methods: From March 1, 1999 to January 2008, minimally invasive MV reoperations were performed in 181 consecutive patients (110 men) with a mean age of 64.5 +/- 12 years. A right-sided lateral minithoracotomy with femoral cannulation for cardiopulmonary bypass (CPB) was used. The principal indication was symptomatic severe mitral regurgitation (mean grade, 3.0 +/- 0.8). Previous procedures were isolated coronary bypass grafting (CABG) in 76 (42%), isolated valve operation, 55 (30%); combined CABG and valve, 16 (9%); and other cardiac operations, 34 (19%). MV replacement was previously performed in 19 patients and MV repair in 31. Mean preoperative left ventricular ejection fraction was 0.54 +/- 0.16., Results: MV repair, including repeat repair, was performed in 109 patients (60%) and MV replacement in 72 (40%). Operations were performed during ventricular fibrillation in 140 (77%), and a transthoracic aortic cross-clamp was used in 31 (17%). Ten patients (6%) underwent beating heart operations with CPB support. Mean total operating time was 176 +/- 50 min. Mean CPB time was 135 +/- 40 min. Thirty-day mortality was 6.6%. Early echocardiographic follow-up revealed excellent valve function in most patients., Conclusion: A minimally invasive approach is a useful alternative for patients requiring a MV procedure after a previous cardiac operation, particularly in patients with patent coronary bypass grafts or previous aortic valve replacement. Very good perioperative results can be achieved with this method.

Purpose: Transapical aortic valve implantation is a new minimally invasive technique for beating heart, off-pump, aortic valve implantation in high-risk patients., Description: The procedure involves antegrade aortic valve implantation using an oversizing technique with direct access and accurate positioning of a stent-based transcatheter xenograft. Procedural steps include placement of femoral arterial and venous access wires, anterolateral mini-thoracotomy, epicardial pacing, and apical pursestring suture placement. Valve positioning is performed under fluoroscopic and echocardiographic guidance during rapid ventricular pacing., Evaluation: Patient screening, especially regarding native aortic annulus diameter and pattern of calcification, is essential for success. Since imaging is crucial, implantations are optimally performed in a hybrid operative theater by an experienced team of cardiac surgeons, cardiologists, and anesthetists., Conclusions: The aim of this article is to outline the technical aspects of the new technique of minimally invasive transapical aortic valve implantation.

Background: Here we report the short- and long-term results of a minimally invasive hybrid approach in 117 patients., Methods: From 1996 to 2007, revascularization of the left anterior descending artery was performed in 1,696 patients by minimally invasive direct coronary artery bypass grafting (MIDCAB), in 89 patients by beating-heart totally endoscopic coronary artery bypass grafting (TECAB) and in 30 patients by arrested-heart TECAB. Of these patients, 117 were scheduled for a hybrid procedure. Revascularization of the left anterior descending artery was performed by either MIDCAB (107 patients), beating-heart TECAB (8 patients) or arrested-heart TECAB (2 patients). Percutaneous coronary intervention of vessels other than the left anterior descending artery was performed 4 to 6 weeks preoperatively (53 cases), intraoperatively (5 cases), or 2 to 45 days postoperatively (59 cases). Demographic data, perioperative outcome, and annual follow-up were obtained from all patients., Results: Minimally invasive bypass and stenting could be completed in all patients. Two high-risk patients (1.9%) died postoperatively. Follow-up of all patients adds up to 208 patient-years. Eight patients died during follow-up. Kaplan-Meier survival was 92.5% (95% confidence interval [CI]: 86.5% to 98.4%) at 1 year and 84.8% (95% CI: 73.5% to 94.9%) at 5 years. Follow-up angiogram of symptomatic patients showed 1 bypass occlusion and 5 in-stent restenosis with need for reintervention. Freedom from major adverse cardiac and cerebral events (including reintervention) and angina was 85.5% (95% CI: 76.9% to 94.1%) at 1 year and 75.5% (95% CI: 62.7% to 87.3%) at 5 years., Conclusions: Minimally invasive hybrid coronary revascularization is a safe approach with good long-term results. It should be performed in selected patients at centers with considerable experience in minimally invasive bypass surgery and requires close cooperation between cardiologists and surgeons.

Minimally invasive techniques for transcatheter aortic valve implantation are rapidly developing. Feasibility of off-pump, sternal-sparing aortic valve implantation has already been demonstrated, initial clinical results are promising, and there will be further technical improvements. However, any complication, some even unknown thus far, can occur at any time during transcatheter aortic valve implantation requiring conversion to cardiopulmonary bypass and conventional surgery. We present a case of left mainstem occlusion during minimally invasive off-pump transapical aortic valve implantation focusing on bail-out strategies. Due to the "surgical safety-net," cardiopulmonary bypass was immediately established, and after coronary bypass grafting, the patient recovered and was discharged from the hospital.

Background: The aim of this study was to evaluate long-term results of surgery for type A aortic dissection in non-Marfan patients with histologically confirmed cystic medial necrosis., Methods: We reviewed our institutional database to identify non-Marfan patients who underwent surgery for acute type A dissection between October 1994 and May 2006 (n = 188). Pathology reports and histologic analyses were available in 174 patients, which form the focus of this study. Long-term results of patients with histologic evidence of cystic medial necrosis in their resected aorta were compared with patients with other causes of aortic dissection., Results: A total of 137 patients (79%) survived to discharge from the hospital. Cystic medial necrosis was present in 89 of these 137 patients (65%, group 1). The remaining 48 patients showed a different histologic pattern (group 2). Long-term follow-up was available in 100% of survivors and was 41 +/- 30 months long. Freedom from late death was 82% in group 1 and 74% in group 2 (p = 0.24). Although aortic reoperation was required in more group 1 patients (17% versus 10%), this difference failed to reach statistical significance (p = 0.3)., Conclusions: The aortic reoperation rate after acute type A dissection may be higher among patients having cystic medial necrosis. We recommend that non-Marfan patients with histologically confirmed cystic medial necrosis undergo the same thorough postoperative surveillance as Marfan patients do.

Reoperative heart valve replacement for degenerated xenografts is associated with an increased surgical risk. We used our experience with transcatheter transapical aortic valve implantation to perform a transapical off-pump aortic valve-in-a-valve implantation. Hemodynamic function was excellent and the patient had a fast and uneventful recovery.

Background: The purpose of this study was to analyze the 5- to 8-year clinical results after prospectively randomized stentless versus conventional aortic valve replacement., Methods: Two hundred twenty-three patients received stentless (Freestyle or Toronto, n = 127) or conventional stented (CE porcine, n = 96) xenograft aortic valve replacement between March 1996 and March 1999 using a prospectively randomized protocol and were discharged from the hospital. Patient age at operation was 71.8 +/- 6.7 years stentless and 74.9 +/- 4 years stented (p < 0.05). There were no significant differences regarding preoperative morphologic and hemodynamic variables. Aortic annulus diameter indices were comparable at 13.5 mm stentless and 13.6 mm stented. Follow-up after 6.9 +/- 0.8 years is complete for 95.6% of the patients at a total of 1,533 patient-years. Analysis of variance, unpaired t test, univariate (chi2), and survival analysis (log rank) were performed., Results: Eight-year survival was 78.1% +/- 3.8% stentless versus 66% +/- 4.9% stented (p = 0.04); mean survival was 97 months stentless versus 88 months stented. At most recent follow-up, New York Heart Association functional class was 1.6 +/- 0.6 stentless versus 1.5 +/- 0.7 stented (p = not significant); ejection fraction was 61% +/- 11% versus 61% +/- 8% (p = not significant); transvalvular maximum flow velocity was 23 +/- 9 mm Hg versus 37 +/- 15 mm Hg (p < 0.01). Thrombembolic events occurred in 2 of 7 patients, including 2 of 6 patients suffering major stroke (p = not significant). Most (93%) of the patients were satisfied with the postoperative course, having a significantly improved quality of life., Conclusions: Midterm results after xenograft aortic valve replacement are satisfactory. Overall survival is significantly better after stentless aortic valve replacement in this series. However, there was no cause and effect relationship between lower transvalvular pressure gradient. Fewer thrombembolic events and better survival rates were proven.

Background: Minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending artery has become a routine operation. Here we present the experience after more than 1300 MIDCAB procedures with up to 7 years of follow-up., Methods: All patients undergoing standard MIDCAB between 1996 and 2004 were included. Long-term follow-up information about health status, major cardiac and cerebral adverse events, and freedom of angina was collected annually by a questionnaire or personal contact. Preoperative, intraoperative, and postoperative data could be completed for all 1347 patients. Five-year follow-up was available for 450 patients and 7-year follow-up for 194 patients., Results: Mean age was 63.2 years (range, 25 to 92 years) and mean ejection fraction was 0.61 +/- 0.14. In 23 patients (1.7%), intraoperative conversion to sternotomy or CPB, or both, was necessary. Early postoperative mortality was 0.8% (n = 11), and 0.4% (n = 5) had a perioperative stroke. A routine postoperative angiogram in 709 patients showed 95.6% early graft patency. Short-term target vessel reintervention was needed 55 patients (4.1%): 10 had percutaneous transluminal coronary angioplasty/stent and 45 had reoperation. A repeat angiogram at the 6-month follow-up was available in 350 patients and demonstrated 94.3% graft patency. Kaplan-Meier analysis revealed a 5-year survival of 91.9% (95% confidence interval [CI], 90.1% to 93.8%) and a 7-year survival of 89.4% (95% CI, 86.7% to 92.1%). The freedom of major adverse events and angina was 89.5% (95% CI, 87.4% to 91.5%) after 5 years and 83.3% (95% CI, 79.0% to 87.5%) after 7 years., Conclusions: MIDCAB can be safely performed with low postoperative mortality and morbidity. The excellent short-term and long-term survival as well as freedom from major adverse cardiac and cerebral events and angina compare favorably with stenting and conventional surgery.

Background: The bovine jugular vein conduit (Contegra [Medtronic, Inc, Minneapolis, MN]) is one option for right ventricular outflow tract reconstruction. We examined the effect of patient age, conduit size, hemodynamics, and cardiac malformation on early and mid-term outcome., Methods: Seventy-eight bovine jugular vein implantations were performed over 5 years. Follow-up averaged 31 +/- 17 months. Risk factor and adverse event analyses for graft dysfunction were performed by multivariate logistic regression and Kaplan-Meier analysis., Results: There was no early mortality. Two late deaths occurred after 9 and 15 months. Early postoperative echocardiography revealed bovine jugular vein regurgitation greater than 2+ in 10 patients, all of which had conduit dilatation, had received a 12-mm conduit, and had a right-ventricular-to-left ventricular pressure ratio greater than 0.6. Two additional patients had severe conduit incompetence develop at the 2-year follow-up. During follow-up, mean gradients increased from 15 to 23 mm Hg (p = 0.03) and stenosis at the distal anastomosis occurred in 25% of patients. Percutaneous interventions were performed in 19 patients (24.4%). Conduit exchange was required in 10 patients (12.8%) after a mean of 14.9 months for severe graft incompetence (8 patients) and progressive supravalvular stenosis (2 patients). Freedom from reoperation was 77.6% and 59.3% at 1 and 4 years for patients less than 1 year of age compared with 93.5% and 87.4% for patients older than 1 year of age (p < 0.001). Risk factors for reoperation were age less than 1 year, correction of truncus arteriosus, conduit size of 12 mm, and persistently elevated right-ventricular-to-left ventricular pressure ratio greater than 0.6 (p = 0.001 each)., Conclusions: Bovine jugular vein implantation is associated with low reoperation and acceptable reintervention rate in patients older than 1 year of age. In infants with persistently elevated right ventricular pressure, reoperation rate was high and had to be compared with other established surgical options.

Background: Percutaneous aortic valve implantation has recently been performed in nonsurgical patients with severe aortic stenosis. Retrograde valve delivery has been problematic because of the size of the delivery system and concomitant peripheral vascular disease. We investigated a minimally invasive approach through the left ventricular apex for antegrade placement of a device-deliverable valve., Methods: Transapical aortic valve implantation was performed using a 23-mm equine valve mounted on a stainless steel stent in 24 swine (weight range, 35 to 45 kg). A limited or full sternotomy approach was used to access the apex of the heart. The crimped valve was introduced through a sheath in the left ventricular apex. Fluoroscopy and echocardiography were used for guidance. Deployments were performed on the beating heart either with ventricular unloading using femoral extracorporeal circulation or rapid ventricular pacing., Results: All valves were successfully delivered at the selected target site with acceptable visualization of the noncalcified aortic annulus. Valve migration occurred during eight deployments (two distal and six retrograde) secondary to persistent cardiac output, unfavorable annular anatomy, and dislodgement by the delivery catheter. Exact positioning of the nonmigrated valves at the aortic annulus was examined by necropsy of all animals at the end of the procedures. Paravalvular leak was noted in 14 of 18 (77.8%) valves remaining in situ., Conclusions: The transapical approach was used for the successful antegrade placement of a stented valve, obviating the technical problems associated with a large delivery system transiting the peripheral vascular system. Stent design contributing to paravalvular leak remains problematic.

Background: Conventional redo coronary artery bypass grafting is associated with an increased risk of mortality and morbidity as a result of manipulation of patent grafts, mediastinitis, and the presence of pericardial adhesions. Minimally invasive direct coronary artery bypass grafting may be an alternative approach in selected patients., Methods: From January 1997 to October 2003, 46 patients (mean age, 66 +/- 7.4 years) underwent minimally invasive direct coronary artery bypass grafting using the left internal thoracic artery to the left anterior descending artery on the beating heart as a reoperation. Patients after previous cardiac operation by means of median sternotomy without use of the left internal thoracic artery presenting with a significant left anterior descending artery stenosis ("culprit lesion") were included. Predicted mortality was 13.6% (range, 2.4% to 72.8%) as calculated by the logistic Euroscore; ejection fraction was 0.531 (range, 0.14 to 0.81). Surgical results were analyzed for mortality, morbidity, duration of the procedure, hospital stay, and event-free survival., Results: Mean operating time was 103 +/- 34 minutes. There were two in-hospital deaths (4.6%), one for malignant ventricular arrhythmia (Euroscore, 60.9%) and the second as a result of severe gastrointestinal bleeding (Euroscore, 29.2%). One patient (2.3%) was successfully reoperated on because of perianastomotic hematoma using the same approach after 6 days. Patients were discharged after 9.4 +/- 2.6 days. There were no other serious adverse events, no stroke, and no myocardial infarction. During follow-up (37 +/- 21 months, complete in 92.1%), 1 patient experienced angina and 6 patients died. The actuarial 4-year survival is 74.8% (95% confidence interval, 51% to 92%), and the actuarial 4-year event-free survival including freedom from angina, major adverse cardiac events, and reintervention is 81% (95% confidence interval, 54% to 97%)., Conclusions: Minimally invasive direct coronary artery bypass grafting can be considered as an alternative approach for redo coronary artery bypass grafting in selected patients.

A 6-week-old patient weighing 4 kg was admitted for surgical correction of anomalous left coronary artery from the pulmonary artery. Reimplantation of the coronary artery with cardiopulmonary bypass was impossible because the patient also had hereditary spherocytosis, which put him at risk for hemolytic anemia. Thus, closure of the left main stem and left internal mammary artery-left anterior descending coronary artery bypass grafting were performed successfully with the heart beating.

Purpose: Atrial-synchronized biventricular pacing is an effective treatment option in patients with heart failure and interventricular conduction delay. Owing to a failed transvenous implantation in some patients, the left ventricular (LV) lead has to be placed surgically, usually by an anterolateral thoracotomy. We used a novel malleable epicardial lead placement tool (Epicardial Lead Implant Tool, Model 10626; Medtronic, Minneapolis, MN) that facilitates lead placement on the posterior aspect of the LV through an anterolateral minithoracotomy., Description: The tool consists of a malleable steel shaft with distal gripping tongs for the epicardial lead. Proximally, a thumbwheel and an actuator button allow fixation and release of the lead on the myocardium., Evaluation: We used this tool in 7 patients through an anterolateral minithoracotomy. All patients had a safe, successful, and rather short procedure. No scopes were required., Conclusions: Epicardial LV lead placement through an anterolateral minithoracotomy is facilitated by using the Lead Implant Tool. Lead placement is achieved by the malleable shaft design, which enables perpendicular implantation of the lead pad on the posterior LV surface with an anterolateral approach.

Background: Our aim is to describe the clinical experience with stentless mitral valve (SMV) replacement with special focus on the functionality of the SMV., Methods: Fifty-two patients (68 +/- 8.5 years old; 36 female) have been prospectively evaluated since August 1997. The chordally supported SMV (Quattro) was implanted for mitral stenosis (n = 26), severe incompetence (n = 17), or mixed lesion (n = 9). Preoperative New York Heart Association class was 3.1 +/- 0.6. Twenty patients received additional intraoperative ablation therapy. Mean follow-up is 37.3 +/- 18.7 months (range, 1 to 65)., Results: Surgery was performed using conventional sternotomy (33) or anterolateral minithoracotomy (19). Atrial rhythm was reestablished in 17 of 20 patients. Six patients operated on early in this series required reoperation, 2 for paravalvular leakage, 2 for functional stenosis, 1 with pannus formation due to underlying rheumatoid disease, and 1 for papillary flap rupture after 5.1 years. Mortality was 1 perioperative (1.9%, nonvalve related) and 1 after reoperation due to multiorgan failure. During late follow-up (30 +/- 7 months postoperatively) 5 patients died of noncardiac causes. Regular echocardiographic control revealed good SMV function (maximum transmitral blood flow velocity 1.7 +/- 0.2 m/s; mean transmitral pressure gradient 3.9 +/- 1.2 mm Hg) and well-preserved ejection fraction postoperatively as well as at most recent follow-up., Conclusions: The clinical experience after 5.5 years of SMV implantation is promising. Preservation of annuloventricular continuity is advantageous. However, long-term durability remains to be proved.

Background: Female gender has been associated with a high prevalence of perioperative morbidity and mortality in coronary artery bypass grafting surgery (CABG). We attempted to determine a potential benefit of off-pump CABG as compared with on-pump CABG (OPCAB) with regard to perioperative outcome in female patients., Methods: Data were prospectively gathered on 2,182 consecutive female patients undergoing CABG either with or without cardiopulmonary bypass from 1996 to 2001. The associations between OPCAB surgery in addition with 22 further preoperative patient-related or treatment-related variables and 26 perioperative outcome variables were assessed with multivariable logistic regression analysis., Results: One hundred fifty-two (7.0%) female patients underwent OPCAB surgery during the study period. Women undergoing OPCAB had higher ejection fractions and received fewer coronary artery bypass grafts than CABG patients. Surgery using OPCAB was associated with shorter hospital stays, less bleeding, less transfusion requirements, and lower mortality than CABG. Furthermore, OPCAB surgery was independently associated with a lower prevalence of high perioperative transfusion requirement, postoperative respiratory insufficiency, postoperative renal insufficiency, and dialysis. Prevalence of postoperative blood loss of at least 500 mL was significantly higher after OPCAB surgery., Conclusions: OPCAB in female patients undergoing coronary artery bypass surgery is safe and seems to be beneficial with regard to perioperative outcome as compared with conventional on-pump CABG. For that reason, off-pump surgery may be an effective method of lowering morbidity and mortality in these relatively high-risk patients.

A 59-year-old male with chronic occlusion of the left anterior descending coronary artery underwent a minimally invasive direct coronary artery bypass procedure using the second generation of a magnetic anastomotic coupling device. Postoperative angiogram demonstrated excellent patency and flow.

We report the case of a 41-year-old patient presenting with anomalous of origin of the right coronary artery from the pulmonary artery (ARCAPA) and severe aortic valve stenosis. Surgical correction was performed by partial (T-shaped) sternotomy. After replacing the bicuspid aortic valve, the right coronary artery ostium was directly reimplanted into the aortic root. The main pulmonary artery was reconstructed using an autologous pericardial patch. Postoperative recovery was uneventful. Four cases involving an association of the bicuspid aortic valve and ARCAPA have been reported in the literature. This potential relationship should be considered whenever diagnosing a bicuspid aortic valve.