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Implantation of a left ventricular assist device through a median sternotomy usually requires cardiopulmonary bypass. However, the biological response to cardiopulmonary bypass is sometimes deleterious in end-stage heart failure patients, as it may compound pre-existing coagulopathy or multiorgan dysfunction. Therefore, there are potential advantages to avoiding cardiopulmonary bypass during left ventricular assist device placement. We describe a technique for off-pump implantation of the Jarvik 2000 left ventricular assist device (Jarvik Heart Inc, New York, NY) through a median sternotomy.

Background: Excess leaflet tissue in Barlow's disease predisposes patients to left ventricular outflow tract obstruction and residual mitral regurgitation after mitral valve repair as a result of systolic anterior motion of the anterior mitral leaflet. In addition to conventional repair techniques such as sliding plasty and leaflet shortening, our approach in Barlow's disease has included the use of large remodeling annuloplasty rings (up to size 40 mm). We report our experience with the use of large rings in Barlow's disease., Methods: From January 2002 to December 2005, 67 patients with Barlow's disease (46 men and 21 women; median age, 55 years; range, 22 to 85 years), mean ejection fraction 0.55 +/- 0.08, and grade 3+ or greater mitral regurgitation underwent mitral valve repair. All had Carpentier type II leaflet dysfunction, with anterior (n = 2), posterior (n = 41), or bileaflet (n = 24) prolapse. Predominant reconstructive techniques were posterior leaflet sliding plasty/plication (n = 65), anterior leaflet triangular resection (n = 16), and chordal transfer (n = 25). Concomitant procedures included coronary artery bypass grafting surgery (n = 8), tricuspid valve repair (n = 20), aortic valve replacement (n = 3), and CryoMaze (n = 22)., Results: Mitral valve repair was successfully completed in all patients. Annuloplasty ring size was 36 mm (n = 17), 38 mm (n = 22), and 40 mm (n = 28). Predischarge transthoracic echocardiography showed absence of systolic anterior motion (n = 67), no or trace mitral regurgitation (n = 62), and mild mitral regurgitation (n = 5). There was no operative mortality., Conclusions: Mitral valve repair can be predictably performed in Barlow's disease with excellent early outcomes. Large annuloplasty rings help minimize the risk of systolic anterior motion and are an important adjunct to established repair techniques in this patient cohort with large annular size and excess leaflet tissue.

Background: Regardless of the indication, tricuspid valve replacement (TVR) has historically been associated with high mortality and morbidity. We report the results of our experience in a high-risk patient population with an emphasis on operative mortality, long-term survival, and valve related events according to the type of prosthesis., Methods: Between 1985 and 1999 TVR was performed in 81 patients (isolated n = 25, combined with valve surgery n = 44, combined with CABG or other n = 12). The mean age was 61 years old (range 19-83 years old). Risk factors included New York Heart Association functional class III/IV (n = 73, 90%), reoperation (n = 58, 72%), urgent/emergent indication (n = 62, 76%), and hepatic dysfunction (n = 13, 16%). Mean pulmonary artery pressure was 34 mmHg. Etiology of tricuspid regurgitation was classified as functional (n = 18, 22%) or organic (n = 52, 64%), or failed previous tricuspid valve surgery (n = 11, 14%)., Results: Tricuspid valve replacement was performed with either a bioprosthetic (n = 34, 42%) or mechanical valve (n = 47, 58%). The overall operative mortality was 22% (n = 18). Risk factors for mortality included urgent/emergent status, age greater than 50 years old, functional etiology, and elevated pulmonary artery pressure. Of the 60 survivors, 26 (43%) died during follow up. After univariate analysis, organic etiology was the only predictor of late death (p = 0.01). Kaplan-Meier survival at 2.5, 5, and 10 years was 80%, 60%, and 45% for bioprosthetic, and 84%, 69%, and 59% for mechanical valves, respectively., Conclusions: Patients requiring TVR are typically high-risk with a high-percentage of reoperations, concomitant cardiac procedures, and end-stage functional class. Operative and overall mortality remains high. Heart failure was the predominant cause of early and late deaths, emphasizing importance of timely referral before the development of end-stage cardiac impairment.

Background: Hearts transplanted from patients undergoing heart-lung transplantation (domino hearts) are unique because they have not been subjected to the deleterious effects of brain-stem death. This study examines the incidence and severity of transplant-associated coronary artery disease in recipients of domino hearts., Methods: We retrospectively reviewed angiographic and clinical data from 97 patients who survived more than 1 year after domino heart transplantation at our hospital. Duration of follow-up ranged from 1 to 11 years after transplantation. The diagnosis of coronary artery disease was based on angiographic criteria., Results: At 1 year, freedom from angiographic coronary artery disease was 99% (70% confidence interval [CI], 97-100), at 5 years it was 83% (70% CI, 78-89), and at 10 years it was 77% (70% CI, 70-84). Donor age, cystic fibrosis in the donor, organ ischemia time during transplantation, and acute rejection after transplantation did not influence risk for the disease. We found an increased incidence of coronary disease in hearts from male donors compared with those from female donors: freedom from disease at 5 years was 72% (70% CI, 63-81) in men vs 93% (87-99) in women. Thirteen patients experienced coronary artery disease at a median of 3 years after transplantation; 4 patients died but most patients remained asymptomatic with angiographically mild disease at their last follow-up examination., Conclusions: We found decreased incidence and severity of transplant-associated coronary artery disease in recipients of domino hearts compared with that reported in recipients of cadaveric hearts. This data supports the continued practice of domino heart transplantation and also supports the hypothesis that brain death may contribute to the development of transplant coronary artery disease in recipients of hearts transplanted from cadaveric organ donors.

Background: Hearts explanted from the recipients of heart-lung transplants provide a unique source of transplants from live donors. This article presents long-term results with this procedure at our center., Methods: We performed a retrospective chart review of domino transplantations performed in our institution between 1989 and 1998., Results: We analyzed 131 domino transplants (123 orthotopic, 8 heterotopic). Domino hearts were from patients with cystic fibrosis (69%), primary pulmonary hypertension (15%), and other diagnoses (16%). The mean recipient pulmonary vascular resistance (PVR) was 3.1 Wood units, 25% of patients having values >4 Wood units. Thirty-day mortality was 13%. The 1-, 5-, and 10-year graft survival was 75% (70% confidence interval [CI], 65-74), 70% (70% CI, 65-74), and 58% (70% CI, 52-64), respectively. Patients with PVR >4 Wood units had 1-year survival (76%; 70% CI, 69-84) similar to that of patients with PVR of < or =4 units (74%; 70% CI, 69-80). Recipients of hearts from patients with cystic fibrosis survived longer (5-year survival, 76%; 70% CI, 71-82) vs 65% for non-cystic fibrosis hearts (70% CI, 57-74) p = 0.09). One-year survival was decreased after transplantation of hearts from female donors (66%; 70% CI, 60-72)) compared with hearts from male donors (85%; 70% CI, 79-90); p = 0.06). Late deaths caused by coronary artery disease and malignancy were uncommon., Conclusion: Although the rate of early mortality after domino transplantation was slightly higher than after cadaveric transplantation, we noted a remarkably low long-term attrition rate in recipients of domino grafts, up to 10 years. In addition, successful transplantation of patients with high PVR supports the hypothesis that heart-lung recipients may provide superior donor hearts for this patient group, many of whom traditional listing criteria would exclude.

Background: This article examines the feasibility of complete conversion from conventional coronary artery operation to routine off-pump coronary bypass operation., Methods: Data on our first 285 off-pump procedures using the Octopus system (Medtronic Inc, Minneapolis, MN) represent our learning curve. This is a complete experience in coronary bypass surgery over 16 months., Results: The cohort was nonselected. All patients had at least two-vessel disease. Eight hundred seven grafts were performed (mean, 2.8 per patient) of which 647 grafts (84%) were arterial (mean, 2.3 per patient). One hundred seventy nine patients (63%) underwent total arterial revascularization. Eight patients required cardiopulmonary bypass; all other operations were completed off-pump. Complications were: mortality, 3 patients (1.5%); renal failure, 24 patients (8%); stroke, 2 patients (< 1%); and atrial fibrillation, 60 patients (21%). The morbidity data and frequency of arterial grafting did not differ from that of 355 patients who underwent coronary bypass operations in a preceding 18-month period., Conclusions: Complete shift from routine use of cardiopulmonary bypass to nonselective off-pump coronary bypass operation is possible with a low conversion rate and without an apparent increase in morbidity or change in technique. Whereas short-term safety and efficacy seem certain, studies of long-term outcome are necessary before the eventual role of off-pump coronary bypass in myocardial revascularization can be defined.