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The prevalence of mitral valve disease has evolved over the past 5 decades from primarily a disease of rheumatic origin to a disease affecting the aging population that encompasses a range of phenotypes from rheumatic mitral stenosis, degenerative mitral regurgitation, and degenerative mitral valve calcification to secondary mitral regurgitation. A reflection on the history of therapy for mitral valve disease is an expedition that follows the birth and development of structural heart intervention from the first percutaneous balloon mitral valvuloplasty to innovative technologies for transcatheter mitral valve repair and replacement. This review will lead you along this journey, pause to acknowledge the feats accomplished, and reflect on the road that lies ahead.

Objectives The aim of this study was to determine clinical and echocardiographic characteristics, mechanisms of failure, and outcomes of mitral valve (MV) surgery after transcatheter edge-to-edge repair (TEER). Background Although >100,000 mitral TEER procedures have been performed worldwide, longitudinal data on MV surgery after TEER are lacking. Methods Data from the multicenter, international CUTTING-EDGE registry were retrospectively analyzed. Clinical and echocardiographic outcomes were evaluated. Median follow-up duration was 9.0 months (interquartile range [IQR]: 1.2-25.7 months) after MV surgery, and follow-up was 96.1% complete at 30 days and 81.1% complete at 1 year. Results From July 2009 to July 2020, 332 patients across 34 centers underwent MV surgery after TEER. The mean age was 73.8 ± 10.1 years, median Society of Thoracic Surgeons risk for MV repair at initial TEER was 4.0 (IQR: 2.3-7.3), and primary/mixed and secondary mitral regurgitation were present in 59.0% and 38.5%, respectively. The median interval from TEER to surgery was 3.5 months (IQR: 0.5-11.9 months), with overall median Society of Thoracic Surgeons risk of 4.8% for MV replacement (IQR: 2.8%-8.4%). The primary indication for surgery was recurrent mitral regurgitation (33.5%), and MV replacement and concomitant tricuspid surgery were performed in 92.5% and 42.2% of patients, respectively. The 30-day and 1-year mortality rates were 16.6% and 31.3%, respectively. On Kaplan-Meier analysis, the actuarial estimates of mortality were 24.1% at 1 year and 31.7% at 3 years after MV surgery. Conclusions In this first report of the CUTTING-EDGE registry, the mortality and morbidity risks of MV surgery after TEER were not negligible, and only

Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).

Temporary epicardial pacing wires are universally used in cardiac surgery and are associated with very low morbidity and mortality. Although rare, serious complications can occur with pacing wires. We present a case of avulsion of a saphenous vein graft side branch caused by removal of pacing wires and leading to pericardial tamponade. Our case favors the use of silk ties rather than hemoclips for occlusion of saphenous vein side branches and illustrates the importance of the location of pacing wires relative to the grafts at the time of coronary artery bypass surgery.

Objectives The aim of this study is to describe the initial experience with versacross transseptal (TS) system for transseptal puncture for the transcatheter mitral valve repair using the MitraClip device. Background Transeptal puncture is a key step in transcatheter mitral valve repair (MVR) and the use of the VersaCross system comprised of a sheath, a dilator and a radiofrequency wire has not been previously described. Methods Prospective single center study of consecutive patients undergoing transcatheter mitral valve repair with the MitraClip device were included. Targeted TS puncture was performed under transesophageal echocardiographic (TEE) guidance. Baseline demographics, procedural characteristics, and major adverse procedural events were collected. Results Twenty-five consecutive patients underwent transseptal puncture using the VersaCross TS system. Transseptal puncture was successful in 100% of patients. The mean time for TS puncture was 3 3 ± 1.6 min with no major adverse procedural events. The mean time from insertion of the VersaCross system to insertion of the MitraClip guide catheter was 3.8 ± 3.0 minutes. Conclusion The VersaCross TS system was successful in all patients for MitraClip procedure with no adverse procedural events and may be associated with increased procedural efficiency.

The management of valvular heart disease has changed dramatically over the past decade with advances in cardiac imaging, the use of novel biomarkers, and the development of transcatheter valve repair and replacement technology. International society guidelines have kept pace to provide recommendations for diagnosis, follow-up, and timing of intervention. The most challenging patient cohort for clinicians are patients with asymptomatic severe disease in whom the optimal timing of intervention can be ill-defined. It is a fine balance between the risks of early intervention on asymptomatic patients and improving patient outcomes by preventing long-term cardiac complications. The key in optimal patient management is gathering the necessary information on patient risk and combining that with the risk, efficacy, and durability of valve interventions to arrive at the appropriate timing for intervention. This group of patients will be the focus of this review as we delve into the natural history, recommended follow-up, and indications for intervention in patients with degenerative aortic and mitral valve disease.

In the race to develop a transcatheter mitral valve, experience with new techniques and devices has resulted in revisiting a previously known complication of surgical mitral valve replacement and r...

Objective To compare antegrade and retrograde cardioplegia administration in minimally invasive mitral valve surgery (MIMS) and open mitral valve surgery (OMS) for myocardial protection. Design Retrospective study. Setting Tertiary care university hospital. Participants The study comprised 118 patients undergoing MIMS and 118 patients undergoing OMS. Interventions The data of patients admitted for MIMS from 2006 to 2010 were reviewed. Patients undergoing isolated elective OMS from 2004 to 2006 were used as a control group. Cardioplegia in the MIMS group was delivered via the distal port of the endoaortic clamp and an endovascular coronary sinus catheter positioned using echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia were used in OMS. Data regarding myocardial infarction (MI) (creatine kinase [CK]-MB, troponin T, electrocardiography); myocardial function; and hemodynamic stability were collected. Measurements and Main Results There was no difference in the perioperative MI incidence between both groups (1 in each group, p = 0.96). No statistically significant difference was found for maximal CK-MB (35.9 µg/L [25.1-50.1] v 37.9 µg/L [28.6-50.9]; p = 0.31) or the number of patients with CK-MB levels >50 µg/L (29 v 33; p = 0.55) or CK-MB >100 µg/L (3 v 4; p = 0.70) between the OMS and MIMS groups. However, maximum troponin T levels in the MIMS group were significantly lower (0.47 µg/L [0.32-0.79] v 0.65 µg/L [0.45-0.94]; p = 0.0007). No difference in the incidence of difficult weaning from bypass and intra-aortic balloon pump use between the MIMS and OMS groups was found. Conclusions Antegrade and retrograde cardioplegia administration during MIMS and OMS provided comparable myocardial protection.

To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.

This study sought to assess the relative merit of surgical correction (SC) versus transcatheter reduction on long-term outcomes in patients with significant paravalvular leak (PVL) refractory to medical therapy.PVL is the most frequent dysfunction following prosthetic valve replacement. Although repeat surgery is the gold standard, transcatheter reduction (TR) of PVL has been associated with reduced mortality.From 1994 to 2014, 231 patients underwent SC (n = 151) or TR (n = 80) PVL correction. Propensity matching and Cox proportional hazards regression models were used to assess the effect of either intervention on long-term rates of all-cause death or hospitalization for heart failure. Survival after TR and SC were further compared with the survival in a matched general population and to matched patients undergoing their first surgical valve replacement.Over a median follow-up of 3.5 years, SC was associated with an important reduction in all-cause death or hospitalization for heart failure compared with TR (hazard ratio: 0.28; 95% confidence interval: 0.18 to 0.44; p 0.001). There was a trend towards reduced all-cause death following SC versus TR (hazard ratio: 0.61; 95% confidence interval: 0.37 to 1.02; p = 0.06). Neither intervention normalized survival when compared with a general population or patients undergoing their first surgical valve replacement.In patients with significant prosthetic PVL, surgery is associated with better long-term outcomes compared with transcatheter intervention, but results in important perioperative mortality and morbidity. Future studies are needed in the face of increasing implementation of transcatheter PVL interventions across the world.

Objective The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

Background The incidence of permanent pacemaker (PPM) implantation is higher following mitral valve surgery (MVS) with ablation for atrial fibrillation (AF) compared with MVS alone. Objectives This study identified risk factors and outcomes associated with PPM implantation in a randomized trial that evaluated ablation for AF in patients who underwent MVS. Methods A total of 243 patients with AF and without previous PPM placement were randomly assigned to MVS alone (n = 117) or MVS + ablation (n = 126). Patients in the ablation group were further randomized to pulmonary vein isolation (PVI) (n = 62) or the biatrial maze procedure (n = 64). Using competing risk models, this study examined the association among PPM and baseline and operative risk factors, and the effect of PPM on time to discharge, readmissions, and 1-year mortality. Results Thirty-five patients received a PPM within the first year (14.4%), 29 (83%) underwent implantation during the index hospitalization. The frequency of PPM implantation was 7.7% in patients randomized to MVS alone, 16.1% in MVS + PVI, and 25% in MVS + biatrial maze. The indications for PPM were similar among patients who underwent MVS with and without ablation. Ablation, multivalve surgery, and New York Heart Association functional (NYHA) functional class III/IV were independent risk factors for PPM implantation. Length of stay post-surgery was longer in patients who received PPMs, but it was not significant when adjusted for randomization assignment (MVS vs. ablation) and age (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.61 to 1.08; p = 0.14). PPM implantation did not increase 30-day readmission rate (HR: 1.43; 95% CI: 0.50 to 4.05; p = 0.50). The need for PPM was associated with a higher risk of 1-year mortality (HR: 3.21; 95% CI: 1.01 to 10.17; p = 0.05) after adjustment for randomization assignment, age, and NYHA functional class. Conclusions AF ablation, multivalve surgery, and NYHA functional class III/IV were associated with an increased risk for permanent pacing. PPM implantation following MVS was associated with a significant increase in 1-year mortality. (Surgical Ablation Versus No Surgical Ablation for Patients With Atrial Fibrillation Undergoing Mitral Valve Surgery; NCT00903370)

The purpose of this study is to report our experience with del Nido cardioplegia (DNC) in the setting of minimally invasive aortic valve surgery. Forty-six consecutive patients underwent minimally invasive aortic valve replacement (AVR) through a “J” ministernotomy: twenty-five patients received the DNC (Group 1) and 21 patients received standard blood cardioplegia (SBC) (Group 2). The rate of ventricular fibrillation at unclamping was significantly lower in the DNC group (12% vs 52%, p=0.004), as well as postoperative creatinine kinase-MB (CK-MB) values (11.4±5.2 vs 17.7±6.9 µg/L, p=0.004). There were no deaths, myocardial infarctions or major complications in either group. Less postoperative use of intravenous insulin (28% vs 81%, p

Recently reported in Europe and United States, disseminated Mycobacterium chimaera infection is a novel clinical entity linked to point contamination of Stockert 3T heater-cooler units used for cardiopulmonary bypass. We present here the first two cases in Canada. Both patients presented with nonspecific extracardiac symptoms 1 year after undergoing minimally invasive mitral surgical repair. Before the right diagnosis was established, the patients were initially treated with prednisone for suspected sarcoidosis. One patient is currently improving, and the other needed mitral valve repair despite aggressive treatment. Because of the nonspecific mode and timing of presentation, a high index of suspicion is necessary for the diagnosis of M. chimaera infection.

Objective The standard approach in treating cardiac myxoma is the median full sternotomy. After recent advances in surgical techniques, the mini right anterior thoracotomy has emerged as an alternative method. Methods We performed a retrospective study to compare the clinical outcomes of the mini right anterior thoracotomy approach with those of the sternotomy approach for resection of cardiac myxoma at the Montreal Heart Institute. There were 20 patients treated using a mini right anterior thoracotomy (4–5 cm) and 23 patients were treated using a median sternotomy. Results No early mortalities were found in either group. Although the cardiopulmonary bypass time and aorta cross-clamp time were not significantly different between the two groups (64.3 mn ± 18 and 37.2 mn ± 15 vs 54.3 mn ± 25 and 37.20 mn ± 2), preoperative blood loss (106 mn ± 95 vs 338 mn ± 270) was significantly less in the mini right anterior thoracotomy group. The intensive care unit and hospital stay (1.65 days ± 1.2 and 5.70 days ± 3) were shorter with the mini right anterior thoracotomy approach. Conclusions A minimally invasive surgery through mini right anterior thoracotomy is a good alternative technique for treating cardiac myxoma. Despite the small size of the experience, there is a clear diminution in preoperative blood loss and an interesting trend toward a shorter intensive care unit and hospital stay.

Objective To compare myocardial protection with retrograde cardioplegia alone with antegrade and retrograde cardioplegia in minimally invasive mitral valve surgery (MIMS). Design Retrospective study. Setting Tertiary care university hospital. Participants The authors studied 97 MIMS patients using retrograde cardioplegia alone and 118 MIMS patients using antegrade and retrograde cardioplegia. Interventions The data from patients admitted for MIMS using retrograde cardioplegia (MIMS retro) between 2009 to 2012 were compared with the data from patients undergoing MIMS with antegrade and retrograde cardioplegia (MIMS ante-retro) between 2006 and 2010 (control group). Cardioplegia in the MIMS retro group was delivered solely through an endovascular coronary sinus (CS) catheter positioned under echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia was used in the MIMS ante-retro group. Data regarding myocardial infarction (MI; creatine kinase Mb, troponin T, electrocardiogram), myocardial function, and hemodynamic stability were collected for comparison. Measurements and Main Results Adequate cardioplegia administration (CS pressure >30 mmHg and asystole) was attained in 74.2% of the patients with retrograde cardioplegia alone. In 23.7% of the patients, the addition of an antegrade cardioplegia was necessary. No difference was observed in the incidence of MI (0 MIMS retro v 1 for MIMS ante-retro, p = 0.3623), difficult separation from cardiopulmonary bypass, and postoperative malignant arrhythmia. No difference was found for maximal creatine kinase Mb (39.1 [28.0-49.1] v 37.9 [28.6-50.9]; p = 0.8299) and for maximal troponin T levels (0.39 [0.27-0.70] v 0.47 [0.32-0.79]; p = 0.1231) for MIMS retro and MIMS ante-retro, respectively. However, lactate levels in the MIMS retro group were significantly lower than in the MIMS ante-retro group (2.1 [1.4-3.05] v 2.4 [1.8-3.3], respectively; p = 0.0453). No difference was observed in duration of intensive care unit stay and death. MIMS retro patients had a shorter hospital stay (7.0 [6.0-8.0] v 8.0 [7.0-9.0] days; p = 0.0003). Conclusion Retrograde cardioplegia administration alone provided comparable myocardial protection to antegrade and retrograde cardioplegia during MIMS, but was not sufficient to achieve asystole in one-fifth of patients.

OBJECTIVE: To analyze patient risk factors and processes of care associated with secondary surgical site infection (SSI) after coronary artery bypass grafting (CABG). METHODS: Data were collected prospectively between February and October 2010 for consenting adult patients undergoing CABG with saphenous vein graft (SVG) conduits. Patients who developed a deep or superficial SSI of the leg or groin within 65 days of CABG were compared to those who did not develop a secondary SSI. RESULTS: Among 2,174 patients identified, 65 (3.0%) developed a secondary SSI. Median time to diagnosis was 16 days (interquartile range [IQR]: 11 - 29) with the majority (86%) diagnosed after discharge. Gram-positive bacteria were most common. Readmission was more common in patients with a secondary SSI (34% vs 17%, p < 0.01). After adjustment, an open SVG harvest approach was associated with an increased risk of secondary SSI (adjusted hazard ratio [HR]: 2.12, 95% confidence interval [CI]: 1.28, 3.48). Increased body mass index (BMI) (adjusted HR: 1.08, 95% CI: 1.04, 1.12) and packed red blood cell (PRBC) transfusions (adjusted HR: 1.13, 95% CI: 1.05, 1.22) were associated with a higher risk of secondary SSI. Antibiotic type, antibiotic duration, and post-operative hyperglycemia were not associated with risk of secondary SSI. CONCLUSIONS: Secondary SSI following CABG continues to be an important source of morbidity. This serious complication often occurs after discharge and is associated with open SVG harvesting, larger BMI, and blood transfusions. Patients with a secondary SSI have longer lengths of stay and are readmitted more frequently.

Background The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our analysis were long-term survival, clinical outcome, and identification of risk factors. Methods Over a 20-year period, 99 consecutive patients underwent pericardiectomy at the Montreal Heart Institute. The indications for operation were idiopathic pericarditis (61%), postsurgical (13%), infectious (15%), postirradiation (2%), and miscellaneous (9%). Associated procedures were performed in 36% of cases. The duration of symptoms was longer than 6 months in 53% of cases, and two thirds of patients were in New York Heart Association class III or IV. Results Hospital mortality was 9% in the whole series and 7.9% in case of isolated pericardiectomy. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality. Conversely, preoperative hepatomegaly and concomitant valvular operation were associated with significantly higher mortality on both univariate and multivariate analysis. In cases of isolated pericardiectomy, the outcome was mainly conditioned by associated comorbidities. The long-term survival was satisfactory, and the functional status at follow-up was improved in most cases. Conclusions The clinical outcome of pericardiectomy for constrictive pericarditis is still marked by high operative mortality. Nevertheless, surgical treatment is able to improve the functional class in the majority of late survivors. Preoperative clinical conditions and associated comorbidities are crucial in predicting the risk of mortality, and early operation seems to be the most appropriate choice. The most suitable surgical strategy in cases of associated valvular operation remains to be determined.

Background Minimally invasive mitral valve surgery (MIMVS) is an established alternative to median sternotomy for mitral valve repair. However, this technique has yet to gain widespread adoption, partly because of concerns that this approach might yield lower repair rates or repairs that are less durable than those performed through a sternotomy. The purpose of this study was to report our inaugural experience with MIMVS, with a focus on mitral valve repair rate and midterm outcomes. Methods Between May 2006 and April 2012, minimally invasive mitral valve repair was attempted in 200 consecutive patients with degenerative mitral disease. The approach used was a 4- to 5-cm right anterolateral minithoracotomy with femorofemoral cannulation for cardiopulmonary bypass. Mean follow-up was 2.9 ± 1.8 years, and follow-up was 99% complete. Results The mitral valve was successfully repaired in all but 2 patients, yielding a repair rate of 99%. Hospital mortality occurred in 2 patients (1%). Intraoperative conversion to sternotomy was necessary in 12 patients (6%), including 1 of the 2 unsuccessful repairs. Mean cardiopulmonary bypass and aortic cross-clamp times were 130.8 ± 41.3 minutes and 104.8 ± 35.6 minutes, respectively. Median hospital stay was 5 days. The 5-year survival and freedom from reoperation were 97.9% ± 1.5% and 98.1% ± 1.3%, respectively. Conclusions A very high repair rate can be achieved using MIMVS for the treatment of degenerative mitral regurgitation, including during the learning phase. Midterm survival and freedom from valve-related reoperation are excellent. MIMVS is a safe and effective alternative to mitral valve repair through a sternotomy.

Objective Minimally invasive mitral valve surgery using peripheral cannulation for cardiopulmonary bypass (CBP) is increasingly prevalent. Although conceptually straightforward, peripheral CBP involves challenges and risks specific to this method of perfusion. The utility of preoperative vascular imaging in predicting these technical challenges and preventing vascular complications was studied. Methods We performed a retrospective analysis of 73 consecutive patients undergoing minimally invasive mitral valve surgery using femorofemoral CBP with intraluminal aortic occlusion balloon catheter. All patients underwent preoperative computed tomography angiogram or magnetic resonance angiography to study the iliofemoral axes. Results None of the patients operated with this technique was found to have arterial stenoses. Patients with a femoral artery diameter of less than 7.3 mm needed bilateral or side-graft arterial cannulation significantly more frequently than patients with larger femoral arteries (46.2% vs 9.1%, P = 0.001). There was a trend toward more frequent modification of arterial cannulation strategy in patients with body surface area less than 1.7 m2 compared with larger patients (body surface area, 1.7–2.0) (26.3% vs 8.3%, P = 0.07). Patients needing high CBP flow rate (>5 L/min) were no more likely to need dual arterial cannulation (18.2% vs 19.1%, P = 0.68). No patient experienced a vascular complication. Conclusions This preliminary study suggests that preoperative vascular imaging and patient evaluation may predict difficulties with femoral cannulation and perfusion, which can lead to better preoperative planning and potentially prevent vascular complications. Further data will be accumulated and analyzed to confirm these findings.

Background With improved durability of contemporary bioprostheses, surgeons are now recommending biologic valves in younger patients. However, long-term outcomes of patients younger than 60 years old undergoing biologic aortic valve implantation are not well known. Methods From November 1991 to March 2011, 144 patients less than 60 years old underwent aortic valve replacement (AVR) with Carpentier-Edwards pericardial valves (Edwards Lifesciences, Irvine, CA). Mean follow-up was 10 ± 4 years. Outcomes were reported according to published guidelines. Results Seventy-five percent of patients were male, with a mean age of 51 ± 9 years. Actuarial survival rates including early deaths were 89% ± 3%, 79% ± 4%, and 57% ± 6% after 5, 10, and 15 years of follow-up, respectively. Survival of patients was comparatively lower than a gender- and age-matched general population at all time points. The freedom from major adverse cardiac events (myocardial infarction, heart failure, hemorrhage, thromboembolic event, and endocarditis) was 89% ± 3%, 87% ± 3%, and 75% ± 6% at 5, 10, and 15 years after surgery. The freedom rate from prosthetic valve dysfunction was 97% ± 2%, 84% ± 4%, and 57% ± 6% at 5, 10, and 15 years after surgery. Patients with a diagnosis of structural valve deterioration (29 of 37, 78%) underwent reoperation 11 ± 5 years after the initial valve replacement with no perioperative mortality. Conclusions In patients younger than 60 years undergoing AVR, the Carpentier-Edwards Perimount bioprosthesis provided satisfactory clinical outcomes. However, late survival was inferior to an age- and gender-matched population. Structural valve deterioration and the need for reintervention were common late after implantation, but reoperation for prosthetic valve dysfunction was associated with a very low risk of mortality.

Objective Functional ischemic mitral regurgitation (FIMR) increases mortality independently of the baseline characteristics and ventricular function. The effect of treating FIMR with annuloplasty is unclear when mitral regurgitation is moderate. Myocardial revascularization alone has been shown to improve mitral valve function. Methods We randomized 31 patients with moderate (grade 2-4) FIMR to receive either coronary artery bypass grafting (CABG) alone or CABG plus downsizing mitral ring annuloplasty. The patients were followed up for clinical outcomes and echocardiographic assessment of mitral valve function and left ventricular dimensions at 3 and 12 months. Clinical improvement was assessed using the Minnesota quality-of-life questionnaire, 6-minute walk test, and brain natriuretic peptide levels. Results The clinical course was similar in the 2 groups of patients during the study period. FIMR was perfectly corrected intraoperatively in the ring group. Echocardiographic follow-up at 3 months showed no difference in the FIMR grade between the 2 groups (66% less than grade 2 in the CABG alone and 86% in the CABG plus ring group; P = .316). The improvement in the CABG alone group was even more marked at 12 months (85% less than grade 2 in the CABG group and 85% in the CABG plus ring group). The left ventricular ejection fraction was significantly better at 3 months in the CABG alone group, although at 12 months, the left ventricular ejection fraction in the 2 groups had improved similarly. Conclusions Although initially effective at reducing moderate FIMR, the addition of a ring did not change the clinical course after CABG surgery. At 12 months, no echocardiographic difference was found in terms of residual mitral regurgitation, left ventricular dimensions and function, or clinical outcomes.

Background The CarboMedics mechanical prosthesis (CarboMedics Inc, Austin, TX) has been used for mitral and aortic valve replacement for more than 20 years in our institution. This study describes the long-term survival of patients with this prosthesis as well as the valve-related events. Methods Between June 1988 and May 2010, 3,297 patients underwent either single aortic valve replacement (AVR) (2,242 patients) or mitral valve replacement (MVR) (1,055 patients) with the CarboMedics mechanical valve prosthesis. They were followed annually for valve-related complications at the Montreal Heart Institute valve clinic. Results Operative mortality was 4% with AVR and 7% with MVR. Total follow-up was 23,671 patient-years (range, 1 month to 21 years; average, 7.5 ± 5.3 years). At 20 years, patient freedom from late mortality was 43.2% in the AVR group and 40.9% in the MVR group. Freedom from valve-related mortality was 78.3% for AVR and 74.6% for MVR. Freedom from thromboembolic event was 91.6% for AVR and 88.5% for MVR. Freedom from reoperation was 89.2% for AVR and 80.3% for MVR. Freedom from bleeding event was 89.5% for AVR and 88% for MVR. Freedom from endocarditis was 97.3% for both AVR and MVR. Freedom from valve thrombosis was 98.9% for AVR and 91.4% for MVR. There was no structural valve failure in our cohort. Conclusions The CarboMedics valve is an effective and durable mechanical valve prosthesis with a low event rate and no structural failure at 20 years.

Objective To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS). Methods Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P Results Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P = .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P Conclusions Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.

Several methods of aortic clamping have been described for minimally invasive mitral valve surgery (MIMVS). The aim of this study was to compare the endoaortic balloon occlusion technique with the transthoracic clamp approach in terms of perioperative outcomes.Between May 2006 and October 2011, a total of 259 patients underwent MIMVS through a 4 to 5 cm right anterolateral minithoracotomy. In 243 (93.8%) of these, the aorta was clamped using either the endoaortic balloon occlusion technique (endoballoon, n = 140) or the transthoracic clamp technique (transthoracic, n = 103).Patients in the endoballoon group had significantly longer operating time (4.3 ± 1.0 hours vs 3.2 ± 0.8 hours, p0.001), cardiopulmonary bypass time (143 ± 44 minutes vs 111 ± 29 minutes , p0.001), and cross-clamp time (114 ± 38 minutes vs 86 ± 23 minutes , p0.001). Perioperative blood loss was higher in the endoballoon group (287 ± 239 mL vs 213 ± 189 mL, p = 0.008) as was the mean postoperative creatinine kinase-MB level (36 ± 44 μg/L vs 26 ± 12 μg/L, p = 0.011). The repair rate was 99% or greater in both groups (p = 0.99). All patients left the operating room with no or trivial residual mitral regurgitation on transesophageal echocardiographic evaluation. In the endoballoon group there was 1 stroke (1%) and 5 myocardial infarctions (4%), compared with 2 strokes (2%) in the transthoracic group (p = not significant). There were 4 cases of postoperative cardiogenic shock, all of which occurred in the endoballoon group (p = 0.14). In-hospital mortality occurred in 2 patients from each group (p = 0.99).Minimally invasive mitral valve surgery can be performed successfully using either the endoaortic balloon technique or the transthoracic clamp approach. However, the transthoracic technique results in shorter operation time, less perioperative bleeding and better myocardial protection.

Background The impact of a transvalvular pacemaker lead on the progression of tricuspid regurgitation (TR) after tricuspid valve (TV) repair has not been clearly demonstrated. The aim of this study was to evaluate the presence of a transvalvular pacemaker lead as a risk factor for TR after TV repair in a large patient cohort. Methods A retrospective review included 791 patients who underwent TV repair at our institution from 1977 to 2008. All patients bearing a transvenous pacemaker implanted either preoperatively or within 30 days of surgery were categorized in the "PACE" group (n = 176), the remaining patients were categorized in the "NO PACE" group (n = 615). Results Mean age was 61 ± 11 years, and 575 patients (73%) were female. Mean follow-up was 5.8 ± 5.5 years. Operative mortality was 13%. At discharge, TR severity was 3+ or greater in 10% and 15% of patients in the PACE and NO PACE groups, respectively ( p = 0.19). Multivariate analysis using a Cox regression model identified the presence of a transvenous pacemaker as an independent risk factor for recurrence of TR 2+ or greater (hazard ratio [HR] 1.60, p = 0.008) and TR 3+ or greater (HR 1.47, p = 0.046) at last follow-up. The presence of a transvenous pacemaker was also a significant independent predictor of late mortality (HR 2.12, p = 0.02). Conclusions In patients undergoing tricuspid valve surgery, the presence of a transvenous pacemaker implanted either preoperatively or within 30 days of surgery is associated with a significantly increased risk of persistent or recurrent TR at late follow-up.

Background The risk of aortic valve replacement (AVR) for patients after mediastinal radiation therapy (MRT) remains unaccounted for in traditional risk scores. The aim of this study was to examine perioperative and midterm outcomes in patients undergoing AVR after MRT in the current era. Methods From 2000 to 2016, 49 consecutive patients previously exposed to MRT underwent AVR with or without concomitant procedures at a single center. Patients were divided into two groups: isolated AVR (n = 18) and AVR with concomitant procedures (n = 31). The logistic European System for Cardiac Operative Risk Evaluation II mean score was 2.8% ± 3.4% and The Society of Thoracic Surgeons mean score was 1.7% ± 1.5%. Median follow-up was 6.6 years and was 90% complete within 12 months of study closure. Results Overall inhospital mortality was 10% (0% in the isolated group versus 16% in the concomitant group; p = 0.14). A total of 21 patients (47%) died at follow-up. Mean interval to death was 2.0 ± 1.1 years from surgery in the isolated group versus 1.4 ± 1.6 years in the concomitant group ( p = 0.18). Actuarial survival was 93% ± 6%, 73% ± 11%, and 65% ± 13%, at 1, 3, and 5 years, respectively, in the isolated group versus 74% ± 8%, 44% ± 11%, and 37% ± 11% in the concomitant group ( p = 0.03). Conclusions Isolated AVR can be performed safely in patients with MRT-induced disease. In contrast, AVR with concomitant procedures is associated with high mortality, which is vastly underestimated using traditional risk scores. In both groups, survival at 5 years is markedly impaired.

Objective To address the clinical consequences related to chest tube clogging, a novel chest drainage apparatus, the PleuraFlow Active Tube Clearance System (Clear Catheter Systems, Bend, OR), was developed. The aim of this world's first clinical experience study was to follow clinicians using the PleuraFlow system to assess usability issues and potential areas of improvement in the heart surgery setting. Methods A user preference study was conducted to assess how specified users (surgeons, nurses, and intensive care physicians) used the PleuraFlow system to achieve specified goals in an efficient manner. Data were collected from patient charts and by a questionnaire that they had filled. Results All the surgeons (n = 7) noted that the device was not any more difficult to insert than a conventional chest tube and was easy to assemble and use. There were no reports of malfunction or complications related to the installation or use of the system. A majority, 77% (24/31), of nurses felt that the device was more time efficient than stripping, milking, or tapping the chest tubes to keep them open. A majority (16/19, 84%) of the PleuraFlow chest tubes and guide tubes were removed together in one piece within 1 day of surgery (on postoperative day 1). Conclusions Overall, the physicians and nurses rated the PleuraFlow system positively for its ability to be incorporated into the postoperative workflow of managing the drainage of patients after heart surgery. This device may be useful to allow caregivers to be certain that chest tubes are functioning in the early hours after surgery, when active bleeding is resolving and when complications from undrained blood can ensue.

Perioperative graft failure following coronary artery bypass grafting (CABG) may result in acute myocardial ischaemia. Whether acute percutaneous coronary intervention, emergency reoperation or conservative intensive care treatment should be used is currently unknown. Between 2003 and 2009, 39 of the 5598 patients who underwent isolated CABG surgery underwent early postoperative coronary angiography for suspected myocardial ischaemia. Following angiography, two groups were identified: patients who underwent immediately reintervention (group 1); and those treated conservatively (group 2). Primary study endpoints were mortality and postoperative myocardial infarct size. Postoperative coronary angiography revealed early perioperative bypass graft failure in 32 of 39 patients. Acute percutaneous coronary intervention was performed in 15 patients, redo-CABG in 4 patients and conservative treatment in 13 patients. The number of failing bypass grafts were significantly higher in group 1 compared with group 2 (P = 0.0251). A trend toward lower post-procedural peak cardiac troponin T and creatinine phosphokinase serum levels in group 1 was observed (163.0 vs. 206.0 and 4.35 vs. 5.53, respectively) (P = 0.0662 and 0.1648). Early reintervention may limit the extent of myocardial cellular damage compared with conservative medical strategy in patients with myocardial ischaemia due to early graft failure.

Background The definition and incidence of patient-prosthesis mismatch (PPM) in the mitral position are unclear. Objectives To determine the impact of PPM on late survival and functional status after mitral valve replacement with a mechanical valve. Methods Between 1992 and 2005, 714 patients (mean [± SD] age 60±10 years) underwent valve replacement with either St Jude (St Jude Medical Inc, USA) (n=295) or Carbomedics (Sulzer Carbomedics Inc, USA) (n=419) valves. There were 52 concomitant procedures (50 tricuspid annuloplasties, 25 foramen oval closures and 20 radiofrequency mazes). The mean clinical follow-up period was 4.4±3.3 years. The severity of PPM was established with cut-off values for an indexed effective orifice area (EOAi) of lower than 1.2cm 2 /m 2 , lower than 1.3cm 2 /m 2 and lower than 1.4cm 2 /m 2 . Parametric and nonparametric tests were used to determine predictors of outcome. Results The prevalence of PPM was 3.7%, 10.1% and 23.5% when considering values of lower than 1.2cm 2 /m 2 , lower than 1.3cm 2 /m 2 and lower than 1.4cm 2 /m 2 , respectively. When considering functional improvement, patients with an EOAi of 1.4cm 2 /m 2 or greater had a better outcome than those with an EOAi of lower than 1.4cm 2 /m 2 (OR 1.98; P=0.03). When building a Cox-proportional hazard model, PPM with an EOAi of less than 1.3cm 2 /m 2 was an independent predictive factor for midterm survival (HR 2.24, P=0.007). Other factors affecting survival were age (HR 1.039), preoperative New York Heart Association class (HR 1.96) and body surface area (HR 0.31). Conclusions In a large cohort of patients undergoing mitral valve replacement with mechanical prostheses, PPM defined as an EOAi of lower than 1.3cm 2 /m 2 significantly decreased midterm survival. This level of PPM was observed in 10.2% of patients. Patients with an EOAi of 1.4cm 2 /m 2 or greater had greater improvement of their functional status.

Isolated hemodynamically significant ventricular septal defects (VSD) were previously treated surgically. Since the introduction of percutaneous (PC) devices, the management of isolated VSD has evolved. In our center, Amplatzer devices have been implanted for selected isolated perimembranous VSD since 2002.The charts of all isolated PC perimembranous VSD closures and all surgical closures performed since 2002 were reviewed retrospectively. Clinical, electrocardiographic, and echocardiographic data were analyzed. The preclosure, immediate postclosure, and 1-month, 6-month, and 12-month postclosure results were assessed.Thirty-seven patients underwent PC closure, and 34 had surgical treatment. Mean follow-up was 42.1 ± 26.0 months. The PC group was significantly older (p0.01) and larger in size (p0.001). Surgical patients had more severe congestive heart failure and a significantly lower VSD gradient (p0.004). At follow-up, there were no differences in the incidence of residual shunting between the two groups (p = 0.92). All valvular regurgitations improved over time, except for 3 aortic regurgitations (5.4%) in the PC group that got worse. Two permanent pacemakers were implanted for early complete heart block in the PC group, and one was implanted in the surgical group (p = 0.94).The surgical results in our population were excellent. The selection of patients with perimembranous VSD remains a challenge to avoid post-PC intervention complications such as heart block and aortic insufficiency. For isolated VSD, PC closure, which avoids the morbidity of open heart surgery, should be considered as part of the therapeutic armamentarium.

Background and aim of study: This study evaluated the long-term outcome of linear, endocardial, radiofrequency (RF) atrial ablation for the treatment of atrial fibrillation (AF) concomitantly to open-heart procedures for acquired cardiac organic disease. Methods: A saline-irrigated “pen-like” RF ablation catheter (Cardioblate®, Medtronic, Minneapolis, MN, USA) was used to perform endocardial lines of conduction block in 293 patients with AF who underwent open-heart procedures between September 2000 and February 2008. Results: Patients (age of 65 ± 11 years) underwent left atrial ablation for permanent (44%), paroxysmal (51%), or undetermined (4.4%) AF. Maintenance in sinus rhythm (SR) at discharge and at the end of follow-up (average 3.3 ± 1.2 years) was observed in 52% and 71% of patients, respectively. Preoperative type or duration of AF did not influence the results (p = NS). Multivariate analysis with a logistic regression model showed left atrial diameter and increasing age were independent predictors of recurrent AF. In this study, return to SR did not influence survival. Conclusions: This study confirmed that concomitant intraoperative RF ablation is an effective technique to restore long-term SR after cardiac surgery in patients with preoperative AF but does not influence long-term survival. (J Card Surg 2010;25:608-613)

Background The use of 2 internal thoracic artery (ITA) grafts increases survival 10 years after coronary artery bypass grafting (CABG) compared with single ITA grafting. Statin treatment was also shown to decrease development and progression of saphenous vein graft atherosclerosis. This study examined the effect of statin treatment on long-term survival after CABG. Methods Operative, survival, and pharmacologic data of 6655 patients who underwent CABG with ITAs between 1995 and 2007 in our institution were obtained. Results Patients with bilateral ITA grafts had an average 10-year-survival rate of 83% ± 2% compared with 67% ±1% in patients with single ITA grafts ( p = 0.0001). Statin treatment caused a significant decrease in the long-term risk of death among patients who underwent single ITA grafting (hazard ratio [HR], 0.735, p = 0.0001). However, statin treatment had no effect on the risk of long-term death among patients who underwent bilateral ITA grafting (HR, 1.053; p = 0.7806). Conclusions Statin treatment initiated early after grafting improved long-term survival in patients with a single ITA graft but not in those with bilateral ITA grafts. Survival of statin-treated patients with single ITA grafts was similar to bilateral ITA patients.

Background Mechanical circulatory support systems (MCSS) have been available in Canada since 1986. Accepted indications include bridging to transplantation or recovery. The present study reviewed the results following MCSS implantation at the Montreal Heart Institute (Montreal, Quebec). Methods From September 1987 to September 2006, 43 MCSS were implanted (32 Thoratec [Thoratec Corporation, USA], nine CardioWest TAH [SynCardia Systems Inc, USA], two Novacor [WorldHeart Corporation, Canada]) in 43 patients (mean [±SD] age 44±13 years; range 19 to 64 years). Indications for implantation included cardiogenic shock due to ischemic (n=19), viral (n=10) or other types of cardiomyopathies (n=14). Results The mean ejection fraction before implantation was 17.6±6.5% (range 10% to 45%). Before MCSS implantation, most patients showed signs of endorgan failure, including mechanical ventilation (77%), central venous pressure higher than 16mmHg (44%), oliguria (35%) and hepatic dysfunction (19%). The mean duration of MCSS support was 22.8±32.8 days (range one to 158 days). Survival to transplantation or recovery was 74%. Only one patient was successfully bridged to recovery. Complications were common during MCSS support. They included re-exploration for bleeding (47%), respiratory failure (44%), renal failure requiring temporary dialysis (40%), infection (33%) and neurological events (16%). Only one patient had device failure. In patients successfully bridged to transplantation, early actuarial survival (one month) following transplantation averaged 71±8% and was 57±9% at one year. Conclusion MCSS support with a left ventricular assist device or a total artificial heart provides an effective means of bridging terminally ill patients to transplantation or recovery. Early survival after transplantation shows satisfactory results. However, these results come at the expense of frequent device-related complications, and device failure remains a constant threat.

Background The prognostic value of right ventricular myocardial performance index (RVMPI) and right ventricular fractional area change (RVFAC) in mitral or aortic valve surgery has not been well described. The main objective of this study is to assess the prognostic value of RVMPI and RVFAC in predicting postoperative mortality or circulatory failure. Methods RVMPI and RVFAC were prospectively measured after induction of anesthesia using transesophageal echocardiography in 50 consecutive patients undergoing corrective mitral or aortic valve surgery. Univariate and multivariate analyses were performed for the primary clinical end point of in-hospital mortality or circulatory failure. Results In the study population, the mean age was 67 ± 9 years. The primary end point occurred in 17 patients (34%); three patients died, and 14 patients presented signs of circulatory failure. Multivariate regression analysis identified RVMPI and RVFAC as variables of prognostic significance. Conclusion Preoperative RVMPI and RVFAC could have an incremental value in predicting postoperative mortality and morbidity in valvular heart surgery. Future studies are needed to validate these results in a larger population.

Background Surgically addressing moderate mitral regurgitation (MR) at the time of aortic valve replacement (AVR) for aortic stenosis remains uncertain. The purpose of this study was to examine the change in moderate (2+) or moderate-severe (3+) MR after isolated AVR for aortic stenosis to determine preoperative factors predictive of improvement in MR. Methods Using an institutional databank of prospectively collected data, all patients undergoing isolated AVR for aortic stenosis with moderate (2+) to moderate-severe (3+) MR between 1994 and 1996 at the Montreal Heart Institute were evaluated. Results Eighty patients with preoperative and postoperative transthoracic echocardiographic follow-up were identified. Preoperative MR was moderate (2+) in 78 patients (97.5%) and moderate-severe (3+) in 2 patients (2.5%). Mitral regurgitation was classified as rheumatic (32%), ischemic (32%), functional (21%), and myxomatous (15%). At 1-year follow-up transthoracic echocardiography, MR improved by 1 or 2 grades in 29 patients (35%), was unchanged in 44 (55%), and worsened in 7 (10%). On multivariate analysis, isolated ischemic and functional MR were the only preoperative factors predictive of MR improvement after AVR ( p = 0.01): 54% of ischemic and 44% of functional MR patients showed improvement in MR after AVR compared with 23% of rheumatic and 17% of myxomatous MR patients. Conclusions Etiology of MR was a significant prognostic factor for improvement in MR grade. Since there was little improvement in the rheumatoid and myxomatous group, replacement or repair should strongly be considered. For functional and ischemic mitral regurgitation, a surgical correction should be performed on an individual basis.

Objective N -acetylcysteine, a potent anti-inflammatory and antioxidant agent, is known to decrease the production of reactive oxygen species after cardiac surgery. The objective of this study was to evaluate the effects of intravenous N -acetylcysteine on clinical and biochemical outcomes after coronary artery bypass surgery with cardiopulmonary bypass. Methods One hundred patients (mean age 60.5 years, range 43-78 years, 89% male) undergoing coronary artery bypass grafting at the Montreal Heart Institute were randomized to receive either N -acetylcysteine (600 mg orally the day before and the morning of the operation, a bolus of 150 mg/kg of intravenous N -acetylcysteine before skin incision, followed by perfusion at 12.5 mg · kg −1 · h −1 over 24 hours; n=50) or placebo (n = 50). The patients and clinical team were blinded to group assignments. Preoperative characteristics were similar between the two groups. Postoperative clinical data (death, myocardial infarction, low-output syndromes, arrhythmias, bleeding, transfusion requirements, and intensive care unit and hospital lengths of stay) and biochemical markers (creatine kinase MB, troponin T, creatinine, hemoglobin, and platelet levels) were evaluated serially over 4 days. Results Clinical outcomes were not significantly different between the two groups with regard to the incidence of death, myocardial infarction, bleeding, transfusion requirements, intubation time, and hospital length of stay. No differences were found in postoperative biochemical markers (troponin T, creatine kinase MB, creatinine, hemoglobin, and platelets) between the groups. No differences were observed between the groups in interleukin-6 production ( P = not significant). Conclusions Prophylactic use of N -acetylcysteine in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass does not lead to improvement in clinical results or biochemical markers. Further strategies to decrease reperfusion injury should be devised.

Sutureless aortic valves are deemed suitable for patients considered at high risk for surgery. The objective of this study is to evaluate the perioperative results of implanting a sutureless valve in elderly persons, compared with a stented biological valve in the aortic position.Between 2011 and 2015, 76 patients underwent aortic valve replacement with the Perceval prosthesis (Sorin Group, Saluggia, Italy). The group was compared with 319 consecutive patients who received aortic valve replacement with the stented valve in that same period.The mean age of patients was 83 ± 2 years in the Perceval group and 83 ± 3 years in the stented valve group (P = .3). Preoperative demographics were similar in both groups. Median cardiopulmonary bypass and crossclamp times were lower in the Perceval group than in the stented valve group (P .001). Mortality was 5% in the Perceval group and 6% in the stented valve group (P = .8). There were more pacemaker implantations in the Perceval group than in the stented valve group (17% vs 8%; P = .02). A subgroup analysis of patients who underwent aortic valve replacement and concomitant procedures showed the same results as the entire cohort.Aortic valve replacement with a sutureless prosthesis resulted in shorter aortic crossclamp and bypass times compared with a stented biological prosthesis. The reduced cardiopulmonary bypass and aortic crossclamp times obtained using the Perceval prosthesis did not translate into perioperative gains in our population of elderly patients.

The purpose of this study was to determine the incidence and significance of abnormal hepatic Doppler venous flow velocities as signs of an abnormal right ventricular filling pattern before cardiac surgery.Retrospective and prospective validation study.Tertiary care hospital.Cardiac surgical patients (121 patients).Not applicable.Demographic, hemodynamic, and echocardiographic variables; vasoactive support; and difficult separation from bypass were compared between patients with or without abnormal hepatic venous Doppler flow. Logistic regression analysis was performed to identify predictors of difficult separation from bypass. Abnormal hepatic venous flow was observed in 23 (29%) and 17 patients (41%) in the retrospective and prospective study. Abnormal hepatic venous flow before surgery was associated with more vasoactive support in both the retrospective (p = 0.0362) and prospective study (p = 0.0163). In the prospective study, abnormal hepatic venous flow was associated with a higher Parsonnet score (p = 0.0005), more atrial fibrillation (p0.0001), pacemaker requirement (p = 0.0124), mitral valve replacement (p = 0.0325), reoperation (p = 0.0050), lower mean arterial pressure to pulmonary artery pressure ratio (p = 0.0127), higher wall motion score index (p = 0.0491), and higher incidence of abnormal right ventricular systolic function (p = 0.0139). Abnormal hepatic venous flow was not found to be an independent predictor of difficult separation from bypass.Abnormal hepatic venous flow velocities before cardiac surgery are frequent and are associated with increased need for vasoactive support after cardiopulmonary bypass. However, it is not an independent predictor of difficult separation from bypass and worse outcome.

Myxomas are the most common primary benign tumors of the heart. The objectives of this study were to review the different surgical approaches to intracardiac myxomas and to assess the long-term prognosis of these patients. We present a retrospective review of 58 intracardiac myxomas surgically removed at the Montreal Heart Institute between September 1975 and May 2002. Nineteen male and 38 female patients with a mean age of 56+/-13 years were operated for cardiac myxoma. Atrial and biatrial approaches were used in 41 and 59% of cases, respectively. The mean follow-up was 8.8+/-6.4 years. Supraventricular arrhythmias and conduction disturbances were the most frequent complications following surgery (39%). One patient died early from malignant arrhythmia and eight other patients succumbed during the follow-up period with two cardiac-related deaths from recurrent myxoma and endocarditis, respectively. The overall 10-year actuarial survival was 86+/-6%. The retrospective comparison of atrial versus biatrial approaches showed marginal difference in the procedural time and no significant difference in blood losses, transfusion requirements, length of stay, postoperative NYHA functional class and survival. Notwithstanding the approach performed, the surgical treatment of cardiac myxomas is associated with a low operative mortality and good long-term outcome.

Background Tricuspid valve replacement is seldom used in clinical practice, but the choice between mechanical and biologic prostheses remains controversial. Methods Between 1977 and 2002, 97 patients underwent tricuspid valve replacement and were followed at the Montreal Heart Institute Valve Clinic. Patients underwent replacement with bioprostheses (n = 82) and mechanical valves (n = 15). Results Patients with bioprosthetic tricuspid replacements averaged 53 ± 13 years of age compared with 48 ± 11 years in those with tricuspid mechanical valve replacements ( p = 0.2). Isolated tricuspid valve replacement was performed in 11 patients (73%) in the mechanical valve group compared with 31 patients (38%. p = 0.01) in the bioprosthetic replacement group. In patients undergoing bioprosthetic tricuspid replacement, 51 (62%) underwent multiple associated valve replacements. The 5-year survival after tricuspid replacement averaged 60% ± 13% in the mechanical valve group and 56% ± 6% in the biologic replacement group ( p = 0.8). The 5-year freedom rate from tricuspid valve reoperation averaged 91% ± 9% in patients with mechanical valves and 97% ± 3% in those with biologic valves ( p = 0.2). Conclusions Patient survival after tricuspid valve replacement is suboptimal but related to the clinical condition at operation. The use of biologic prostheses for tricuspid valve replacement remains a good option in young patients because of limited life expectancy unrelated to the type of tricuspid prostheses at long-term follow-up.