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The use of pacemakers and implantable cardioverter-defibrillators continues to increase for the management of cardiac dysrhythmias and, more recently, heart failure. Long-term complications associated with their use include infection, lead failure, and spurious shocks. Although the risk of infection with intracardiac devices is well known, the clinical presentation of this complication can be insidious, delayed in onset, and difficult to diagnose. We report a case of Aspergillus fumigatus infection of an implantable cardioverter-defibrillator with right-sided endocarditis in a 55-year-old man. The infection presented as persistent pulmonary infiltrates (due to recurrent septic pulmonary embolism) and anemia more than 2 years after implantation of the device. Clinicians should be aware of the variable manifestations resulting from infection of intracardiac devices. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To better understand the outcome of the bicuspid aortic valve (BAV) after valve-sparing root replacement, we evaluated BAV function after its preservation at the time of the ascending aorta (AA) repair. PATIENTS AND METHODS: From January 1, 1994, through March 31, 2002, BAVs were preserved during repair of AA aneurysms in 21 patients (mean +/- SD age, 45+/-12 years; 13 males). We reviewed the clinical and surgical records of these patients for baseline characteristics, operative procedures, and data at latest follow-up. RESULTS: The primary indication for operation was AA enlargement (median diameter, 55 mm; range, 43-65 mm) in 18 patients and severe aortic regurgitation (AR) in 3 patients. Preoperatively, the BAV exhibited mild or moderate stenosis in 5 patients (mean gradient, 25 mm Hg; range, 19-34 mm Hg), moderate AR in 2, and severe AR in 3. Aortic valve repair was performed in 11 patients. Seventeen patients had excision and graft replacement of the enlarged AA, and 4 patients had primary AA repair. There were no perioperative deaths. Moderate or severe AR was relieved in all patients early postoperatively and during follow-up (median, 2.5 years; maximum, 7.6 years). One patient required aortic valve replacement at 4.8 years for AR. An additional patient had recurrent, severe AR but was asymptomatic and has not undergone reoperation. CONCLUSION: Repair of diseased BAVs or preservation of functionally normal BAVs during surgery for AA aneurysms has a low perioperative risk, and early results are encouraging. Additional observation is necessary to determine whether this strategy has real advantages over early aortic valve replacement. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the role of off-pump coronary artery bypass grafting in the treatment of patients with severe recurrent angina after coronary artery bypass grafting who are not suitable for percutaneous coronary intervention and are considered too high risk for conventional on-pump revascularization. PATIENTS AND METHODS: All patients who needed single- or double-vessel revascularization at reoperation with a predicted operative mortality of 10% or higher between March 4, 1994, and December 31, 2002, were studied. Risk stratification was performed using both the Parsonnet risk scoring system and the European System for Cardiac Operative Risk Evaluation. Active follow-up by questionnaire investigated major adverse cardiac events. RESULTS: This study consisted of 84 patients with a median age of 69 years (interquartile range, 62-75 years); 14 (17%) were female. All patients had class III/IV symptoms. Previous operations included multiple coronary artery bypass grafts (15 patients [18%]) and heart transplantation (1 patient [1%]). Internal thoracic artery graft from a previous operation was patent in 43 patients (51%). Perioperative hemodynamic support with inotropes (35%) and intra-aortic balloon pump (14%) or ventricular assist device (2%) was common. The surgical approach varied for each patient. One operative death (1%) occurred. Estimated survival at 5 and 7 years was 77% and 67%, respectively. Late major adverse cardiac events observed during follow-up were cardiac death (n=66), nonoperative reintervention (n=8), and nonfatal myocardial infarction (n=5). CONCLUSION: Off-pump coronary artery bypass grafting can mitigate reoperative risk in patients with an estimated risk of 10% or higher who are undergoing single- or double-vessel revascularization with satisfactory long-term outcome. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate operative management, outcome, and long-term survival in patients with functioning renal and hepatic allografts who underwent cardiac surgery. PATIENTS AND METHODS: We studied all patients who had previously undergone either renal or hepatic transplantation and who subsequently (1986-2001) underwent cardiac surgery at our institution. Data were obtained by retrospective medical record analysis. RESULTS: The study comprised 47 patients with renal (n=34) and hepatic (n=13) functioning allografts. Median time to cardiac surgery from transplantation was 79 months. The most common procedures were as follows: coronary artery bypass grafting, 22 (47%); aortic valve procedures, 11 (23%); and mitral valve procedures, 5 (11%). One patient (2%) died within 30 days of surgery. Renal allograft dysfunction was noted in 5 renal patients (15%) immediately after surgery. Two patients required dialysis postoperatively, 1 of whom required continued dialysis on dismissal. Transient allograft dysfunction, as determined by elevated liver enzyme levels, occurred in 6 hepatic patients (46%). However, all hepatic patients had functional allografts on dismissal. Two patients (4%) developed leg wound infections, and 9 (19%) had respiratory complications. No sternal or mediastinal infection occurred. One- and 5-year survival rates (mean +/- SEM) for all patients were 93%+/-4% and 76%+/-8%, respectively. Of the renal patients, 1- and 5-year survival rates (mean +/- SEM) were 97%+/-3% and 82%+/-8%, respectively. One- and 5-year survival rates (mean +/- SEM) for hepatic patients were 77%+/-12% and 69%+/-13%, respectively. CONCLUSION: Cardiac surgery can be performed safely in kidney and liver transplant recipients, with low early mortality and excellent medium-term survival. In almost all instances, allograft function is well preserved. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To analyze the effect of adjuvant perfusion techniques of the distal aorta on the outcome of traumatic thoracic aortic transections. PATIENTS AND METHODS: From 1973 to 2004, 72 patients (mean age, 39 years) with thoracic aortic transections arrived alive at the emergency department. Nineteen patients arrived in extremis and underwent emergency operations, 42 patients were stable and underwent diagnostic evaluation before surgery (4 patients experienced aortic rupture during evaluation), and 11 patients presented more than 24 hours after the accident. Sixteen patients died before aortic repair could be performed. Operative repair was possible in 53 patients (46 stable and 7 in extremis). Interposition graft was performed in 47 patients, and primary repair was performed in 6 patients. Morbidity, mortality, and paraplegia rate were analyzed. RESULTS: Patients in extremis had a mortality rate of 84% (16 of 19), stable patients had a mortality rate of 11% (4 of 38), patients who experienced rupture during evaluation had a mortality rate of 100% (4 of 4), and patients who underwent delayed operation had a mortality rate of 0% (0 of 11). The paraplegia rate with and without adjuvant distal aortic perfusion techniques was 2% (1 of 41 patients) and 33% (4 of 12 patients), respectively (P=.007). Mortality and paraplegia rates were 4% and 4% for partial bypass (n=24), 42% and 33% for the clamp and sew technique (n=12), 0% and 0% for Gott shunt (n=10), and 29% and 0% for full cardiopulmonary bypass (n=7), respectively. CONCLUSIONS: Although thoracic aortic transections remain a highly lethal injury, hemodynamically stable patients have a low operative mortality. Spinal cord injury is decreased by the use of adjuvant perfusion techniques that maintain distal aortic perfusion during cross-clamping of the aorta. [ABSTRACT FROM AUTHOR]

Prosthetic heart valves have been effectively used for many years. Nonetheless, they are associated with risks of thrombosis and thromboembolic events, as well as anticoagulation-induced bleeding. Substantial changes in anticoagulation measurement and dosing have occurred during the past several years. In this review, the rationale for anticoagulation in patients with prosthetic heart valves, the changes in monitoring and dosing, and the comparison of relevant anticoagulation trials are discussed. On the basis of the existing data, new recommendations regarding lower anticoagulation levels are offered, utilizing a single value goal rather than the traditional therapeutic range. Perioperative management of anticoagulation is discussed in light of the available literature, and major drug interactions are reviewed.

Aortic valve replacement is a lifesaving measure in patients with severe aortic valve disease. In the United States, the most commonly used prostheses are the mechanical and bioprosthetic valves. With mechanical valves, long-term anticoagulation is necessary because of high thrombogenic potential. Bioprosthetic valves have a relatively high incidence of structural failure, especially in younger patients. Aortic valve homografts, derived from human heart donors or autopsy material, provide an alternative to mechanical or animal valves. The advantages of the homograft in comparison with the mechanical prostheses are the low incidence of thromboembolism without anticoagulation and lower valvular gradients in smaller sizes. Homografts are relatively resistant to endocarditis and are the valve of choice during active endocarditis. Their major mode of failure has been aortic regurgitation; however, recent advances in preservation and operative techniques have decreased this problem. Whether implantation of an aortic valve homograft should be the procedure of choice in subsets of patients remains controversial. Herein we review the history, techniques, results, complications, and current indications for aortic valve homografts.

Mitral regurgitation is a common valvular heart disease, particularly in the elderly population. The timing of surgical repair is controversial, but recent literature suggests a new clinical perspective on the management of this disease. Despite receiving medical treatment and having few initial symptoms, patients with mitral regurgitation due to flail leaflets have an excess mortality rate (6.3% per year) and high morbidity. Ten years after mitral regurgitation has been diagnosed, 90% of the patients have either died or undergone an operation. After surgical correction of mitral regurgitation, left ventricular dysfunction is a frequent complication and is the cause of excess heart failure and mortality. This complication is due to preoperative left ventricular dysfunction but is incompletely predictable with use of current methods. Conversely, considerable progress in surgery has resulted in an extremely low operative mortality rate (about 1% in patients younger than 75 years of age) and high feasibility of valve repair, even in patients with anterior leaflet prolapse. These facts have led to the new perspective that early surgical correction (before occurrence of overt symptoms or left ventricular dysfunction) should be considered when patients are diagnosed with severe mitral regurgitation.

Objective: To compare changing clinical characteristics and early and late outcomes for patients treated with either coronary artery bypass grafting or coronary angioplasty at Mayo Clinic Rochester during a 10-year period., Design: We retrospectively analyzed a series of patients with coronary artery disease who were clinically selected for myocardial revascularization from Jan. 1, 1982, through Dec. 31, 1991., Material and Methods: The study population consisted of 7,099 patients treated with coronary artery bypass grafting and 4,937 who underwent coronary angioplasty. To monitor changes in clinical and procedural outcomes over time, we divided the 10-year period into three equal intervals: period I = Jan. 1, 1982, through Apr. 30, 1985; period II = May 1, 1985, through Aug. 31, 1988; and period III = Sep. 1, 1988, through Dec. 31, 1991. Patients who underwent valve or arrhythmia operations along with coronary bypass were excluded from the study, as were those who were treated with angioplasty technologies other than balloon angioplasty., Results: Throughout the study period, use of coronary angioplasty progressively increased (784 procedures in period I and 3,516 in period III). The number of coronary bypass operations increased from period I to period II but declined in period III. Over time, increasing numbers of elderly patients and women were referred for myocardial revascularization. Use of the internal mammary artery as a bypass conduit increased from 23% of cases in period I to 84% in period III. In surgical patients, perioperative myocardial infarction rates declined significantly from 5.7% to 2.0% from periods I to III. For coronary angioplasty, elderly patients, patients with diabetes, and patients with hypertension progressively increased. Multivessel coronary angioplasty increased from 10% of the cases in period I to 15% in period III. Operative mortality rates for both coronary bypass and angioplasty remained stable throughout the study despite the increasing number of high-risk patients., Conclusion: This 10-year experience with coronary bypass and angioplasty at a major referral center reflects the national trend of an aging patient population with coronary artery disease undergoing revascularization procedures.

Objective: To describe a 30-year experience with surgically treated culture-positive active endocarditis., Design: We retrospectively reviewed the microbiologic, clinical, and operative findings and the survival data in 151 patients with culture-positive active endocarditis encountered between 1961 and 1991., Results: The mean age of the 110 male and 41 female patients was 49.8 years. Native valve endocarditis was present in 86 patients, and prosthetic valve endocarditis (PVE) was diagnosed in 65. The aortic valve was involved in 62% of patients, the mitral valve in 25%, and both valves in 10%. The operative mortality was 26%. The most important univariate determinants of mortality were an abscess at operation (P = 0.01) and renal failure (P = 0.03). A trend toward a higher mortality with PVE and staphylococcal infection was noted. For hospital survivors, the 5- and 10-year survival was 71% and 60%, respectively. Univariate determinants of an adverse long-term survival were annular abscess (P = 0.01), renal impairment (P = 0.01), heart failure (P = 0.02), and aortic valve involvement (P = 0.05). On multivariate analysis, the most important adverse determinants of long-term survival were heart failure (P = 0.02), renal impairment (P = 0.02), and PVE (P = 0.03). Thirty patients required a subsequent reoperation; of these, seven required a second and two a third operation. The most common reason for reoperation was periprosthetic regurgitation without infection (N = 19). Four operations were performed for recurrent endocarditis. At 5 and 10 years, the risk of reoperation was 23% and 36%, respectively., Conclusion: Although surgical treatment of culture-positive active endocarditis is still associated with substantial mortality, the long-term outcome of hospital survivors is excellent. Subsequent reoperations for periprosthetic leak are common, but recurrent infection is uncommon.

Objective: To determine whether patients with impaired left ventricular function and one- or two-vessel coronary artery disease who manifest severe ischemia during exercise radionuclide angiography have a lower rate of subsequent cardiac events when initial management is revascularization rather than medical therapy., Design: During a median follow-up of 100 months, we compared the outcome between 37 patients who underwent a revascularization procedure and 22 who received medical therapy at the Mayo Clinic between September 1980 and December 1985., Material and Methods: The revascularization therapy consisted of coronary artery bypass grafting in 31 patients and coronary angioplasty in 6. Overall survival and survival free of initial cardiac events were compared statistically for the medically and surgically treated patients., Results: Eleven deaths occurred in the patients who received medical therapy and 9 in the revascularization group. Five-year overall survival was 58% in the medically treated patients versus 84% in the revascularization group. A significant association was noted between type of treatment and overall survival (adjusted chi 2 = 6.20; P = 0.013). Twenty patients had initial cardiac events--7 in the medically treated group (3 cardiac deaths and 4 nonfatal myocardial infarctions) and 13 in the revascularization group (3 cardiac deaths, 3 out-of-hospital cardiac arrests, and 7 nonfatal myocardial infarctions). Survival free of cardiac events at 5 years was 72% in the medically treated patients and 66% in those who underwent revascularization. No association was detected between type of treatment and survival free of cardiac events., Conclusion: These nonrandomized data suggest that overall survival for patients with one- or two-vessel coronary artery disease, impaired left ventricular function, and severe exercise-induced ischemia may be improved by revascularization, but the subsequent cardiac event rates are not.

Thrombotic stenosis of a Carpentier-Edwards porcine bioprosthesis occurred in two patients within 3 months after aortic valve replacement. Both patients underwent successful replacement of the aortic prosthesis. Although previously reported, this complication of aortic porcine bioprostheses is uncommon.

A case of cerebral air embolism sustained during replacement of the mitral valve resulted in postoperative coma and seizures. Hyperbaric treatment, begun 30 hours after the occurrence of the air embolism, resulted in good immediate and long-term recovery. Mild deficits of the left hemisphere were present at follow-up 53 days after the embolus was sustained, and lesser, minimal residua were present at 14-month follow-up. Hyperbaric treatment is the definitive therapy for cerebral air embolism. Although it is most effective when administered early, the outcome may be excellent even with late treatment.

To analyze the short- and long-term morbidity and mortality among maintenance dialysis patients who have undergone coronary artery bypass operations, we identified 25 such patients at the Mayo Clinic and three recently published large single-center studies that provided sufficient detail for meaningful comparison. Two independent observers reviewed the new information with regard to pertinent historical, clinical, and laboratory data. The perioperative mortality was 20%. Among the perioperative survivors, 1- and 2-year survival rates were 95% and 77%, respectively. The 3-year actuarial survival was 70%. Uniformly, the symptoms diminished, and the need for antianginal medication was decreased. In the three other large published series, the perioperative mortality ranged from 3 to 20%, and coronary artery bypass performed earlier after the onset of the symptoms seemed to result in a lower perioperative mortality. We conclude that elective coronary artery bypass in dialysis patients is associated with acceptable short-term morbidity and mortality and effective relief of symptoms. Surgically treated patients may have a survival advantage. Thus, we advocate aggressive early investigation and surgical treatment of these patients.

Staphylococcus aureus pericarditis and recurrent episodes of hemorrhagic cardiac tamponade developed in a 31-year-old man. He later died of exsanguination and at autopsy was found to have a ruptured infective pseudoaneurysm of the aortic arch. When hemorrhagic pericardial effusions of undetermined cause are encountered, the heart and great vessels should be evaluated as potential sources of the hemorrhage.

The gross surgical pathologic features of the mitral valve were reviewed in 712 patients who had undergone mitral valve replacement at our institution during 1965, 1970, 1975, 1980, and 1985. Among the 452 cases of mitral stenosis, either with or without mitral insufficiency, 99% were attributable to postinflammatory disease and 1% were related to congenital mitral stenosis. Among the 260 cases of pure mitral regurgitation, the two most common causes were a floppy valve (38%) and postinflammatory disease (31%). Moreover, a floppy valve was observed in 73% of the 59 examples of chordal rupture and in 38% of the 16 cases of infective endocarditis. Women accounted for 73% of the 452 cases of mitral stenosis and for 72% of the 530 cases of postinflammatory disease. In contrast, men accounted for 58% of the 260 cases of pure mitral regurgitation, including 76% of the floppy valves and 69% of the infected valves. During the 21 years spanned by the study, the relative frequency of postinflammatory mitral insufficiency progressively decreased, whereas that of floppy mitral valves increased. It is unclear whether aging, heredity, environmental factors, changes in the frequency of acute rheumatic fever, or changes in patient referral practices may account for this observation.

Early patency and late patency have consistently been better with single internal mammary artery grafts than with saphenous vein conduits. To determine the efficacy of these two types of grafts in sequential anastomoses, we performed sequential anastomoses of the left internal mammary artery to the left anterior descending and diagonal coronary arteries in 40 patients and compared the results with those in 58 patients who received sequential saphenous vein grafts. Treatment with dipyridamole (starting 48 hours before operation) and aspirin (added 7 hours after operation) was given to the 40 patients with internal mammary artery grafts and to 32 of the 58 patients in the saphenous vein group. After the bypass procedure, mean blood flows were as follows: 68 ml/min in patients with internal mammary artery grafts, 73 ml/min in patients who received saphenous vein grafts and a placebo, and 99 ml/min in those who received saphenous vein grafts, aspirin, and dipyridamole. Early patency of sequential internal mammary artery grafts to the diagonal and left anterior descending coronary arteries was comparable to that of sequential saphenous vein grafts. Because a substantial late reduction in patency has been noted in sequential saphenous vein grafts, sequential internal mammary artery grafts may be the preferred conduit for coronary artery revascularization.

The term "penetrating aortic ulcer" refers to an ulceration of an atheromatous plaque that extends deeply through the intima and into the aortic media. It may precipitate an intramedial dissection (usually localized) or may rupture into the adventitia to form a pseudoaneurysm. The typical patient with penetrating atheromatous aortic ulcer is elderly and has hypertension, atherosclerosis, and back or chest pain, but pulse deficit, stroke, aortic insufficiency, and compromise of a visceral vessel are not present. Classic aortic dissection and symptomatic thoracic aortic aneurysms are among possibilities in the differential diagnosis. Aortography demonstrates the presence of an aortic ulcer similar in appearance to gastric ulcers seen on barium examination; in addition, an intramural aortic hematoma may be present. Our experience with penetrating aortic ulcers in symptomatic patients indicates that conservative medical therapy leads to recurrence of symptoms and a need for surgical intervention. We present a case that illustrates the salient features of this distinct clinical entity.

Percutaneous transluminal coronary angioplasty is a promising new method of treatment for patients with coronary artery disease. Inflation of a balloon located at the tip of a catheter is used to dilate stenoses. In the first year of the use of percutaneous transluminal coronary angioplasty at the Mayo Clinic, it was applied in 34 selected patients whose severe angina pectoris was related to a single, high-grade coronary artery stenosis. Successful dilation (stenosis opened by 40% or more of the normal luminal diameter) was achieved in 22 patients (65% of the total). Early postangioplasty assessment indicated relief of angina in all of these patients except for one patient who demonstrated coronary spasm that was responsive to medication. Median hospital stay was 3 days. Failure of percutaneous transluminal coronary angioplasty in the remaining 12 patients was usually due to an inability to manipulate the balloon catheter across the stenotic segment. Eleven of these patients had saphenous vein bypass graft surgery, as planned, immediately after the attempted angioplasty. There have been no deaths, but three patients sustained a transmural myocardial infarction. This initial experience with percutaneous transluminal coronary angioplasty indicates that it is a relatively safe and a frequently effective method of relieving coronary stenosis in selected patients with symptomatic coronary artery disease.

Papillary fibroelastomas are benign tumors of the heart and are most often incidental findings at cardiac surgery or autopsy. Rarely, symptoms or even sudden death can occur. We report two cases of cardiac papillary tumors diagnosed by two-dimensional echocardiography and successfully excised. One patient was asymptomatic and had a 1-by 1-cm papilloma of the mitral valve. The other patient had intermittent chest pains and diaphoresis associated with a 1.5- by 1-cm aortic valve papilloma.

During the period November 1979 to October 1984, 19 patients at our institution underwent balloon angioplasty of partial or complete obstruction of aortocoronary artery saphenous vein bypass grafts. The procedures were performed a mean of 38 months after a coronary bypass operation to relieve recurrent angina of at least class 2 in the Canadian Cardiovascular Association functional classification. Graft angioplasty was successful in 16 of the 19 patients, and the location of the lesion (in the origin, body, or distal insertion of the graft) did not seem to be an important factor in achieving a successful result. At a mean follow-up interval of 20 months (range, 1 to 40 months), 14 patients had symptomatic improvement. Two patients required late repeat operation and four had repeat angioplasty because of restenosis. Our experience supports the use of balloon angioplasty in selected patients with bypass graft stenosis, but restenosis remains a substantial problem.

Recurrent angina after coronary artery bypass grafting is due to several factors: graft occlusion, progression of disease, and incomplete revascularization. Of these, incomplete revascularization of diseased but graftable secondary branches of the three major coronary arteries is most amendable to primary surgical treatment. Current operative methods permit endarterectomy or direct bypass grafting (or both) of these smaller vessels. This report details two techniques for revascularization of the anterior septal branch of the left anterior descending coronary artery.

In a retrospective study of 388 patients who had undergone cardiac operations at our institution during two time periods-before (1982) and after (1984) introduction of autologous transfusion-we analyzed the effect of blood conservation efforts and autologous transfusion on blood usage, postoperative complications, and duration of hospitalization. Cell salvage techniques resulted in a significant reduction (P less than 0.0001) in use of not only homologous blood (from a mean of 9.6 units per patient in 1982 to 3.2 units in 1984) but also fresh-frozen plasma and platelet concentrates. We found no significant difference in morbidity or mortality for the two study periods. Although the mean duration of hospitalization decreased from 11.7 days in 1982 to 9.6 days in 1984, this change was probably related to factors other than the introduction of blood conservation efforts. Thus, techniques used to decrease the amount of blood replacement needed for cardiac surgical procedures are beneficial.