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Objective: Morbidity due to sternotomy continues to be a significant clinical problem. Poor approximation of the sternum may lead to complications such as sternal dehiscence, infection, and pain. A device to assist in tensioning and twisting standard steel wires during sternal closure has been developed (TORQ sternal closure device). Manually tightened interrupted wire closures were compared with those tightened and secured with the aid of the device. Performance of the device was assessed clinically., Methods: Four cardiovascular surgeons performed manual and device-assisted closures on a biofidelic model. Closure force was measured to determine the residual force and its intraoperator variation. A retrospective review of patients treated before and after the introduction of the device was conducted. Predicted and actual outcomes were compared for the two groups (manual closure and device-assisted closure)., Results: Biomechanical testing measured a 75% increase in residual closure force (P < 0.001) and a significant reduction in the variability of the closure force (P = 0.045) for device-assisted closures compared with manual closures. In the retrospective study, 3 of 173 manually closed patients had sterile sternal dehiscence and 1 of 173 had a deep sternal wound infection. In the device closure group, 2 of 127 had a sterile sternal dehiscence and no deep sternal wound infections were reported. No other device-related serious adverse events were reported., Conclusions: Biomechanical data showed stronger, more consistent closure forces with the device. The retrospective data attest to the performance of the device.

Background and Aim of the Study: The appropriate management of patients with mitral regurgitation (MR) and left ventricular dysfunction (LVD) is controversial. The study aim was to determine whether the presence of contractile reserve (CR) assessed by dobutamine stress echocardiography (DSE) was associated with improved outcomes., Methods: Death and heart transplantation were analyzed as the primary outcomes associated with the presence of CR. A total of 125 consecutive patients (96 males, 29 females; mean age 60 +/- 12 years) with left ventricular ejection fraction (LVEF) < or = 35% and hemodynamically significant MR underwent DSE between 1999 and 2005. CR was defined as an increase in LVEF of > or = 10% during dobutamine infusion., Results: Among 125 patients, 55 (43.0%) showed evidence of CR. Within five years after DSE, 24 patients (34.3%) in the CR- group and seven (12.7%) in the CR+ group had died or required heart transplantation (p < 0.01, log rank). After adjusting for age, baseline LVEF, NYHA class and moderate/severe tricuspid regurgitation (TR), CR remained an independent predictor of time to death or heart transplantation (HR 0.34; 95% CI: 0.15-0.76, p < 0.01). Improvement in the degree of MR was present at one year in 85.0% of CR+ patients, and in 62.5% of CR- patients (p = 0.03). An improvement of 5% in LVEF was noted in the CR+ group, compared to 0% in the CR- group (p = 0.04)., Conclusion: In patients with advanced LVD and severe MR, CR detected by DSE was associated with significant reductions in the risk of death and heart transplantation.

Background and Aim of the Study: The findings of this single-center experience with the Medtronic Mosaic porcine bioprosthesis were evaluated to determine the clinical performance of the valve., Methods: Between 1994 and 2000, a total of 657 patients was implanted with the prosthesis. Aortic valve replacement (AVR) was performed in 415 patients (mean age 70.5+/-10.7 years; range: 26-89 years) and mitral valve replacement (MVR) in 242 patients (mean age 70.5+/-9.5 years; range: 19-86 years). Concomitant coronary artery bypass (CAB) was performed in 51.1% and 46.7% of AVR and MVR patients, respectively. The majority of patients were aged over 70 years (59.8% AVR, 58.7% MVR)., Results: Survival at six years was 73.0+/-2.4% after AVR, and 74.0+/-5% after MVR (p = NS). Actual freedom from valve-related mortality at six years was 98+/-1% for AVR and 96+/-1% for MVR; freedom from overall thromboembolism (TE) was 86+/-3% for AVR and 89+/-2% for MVR. After AVR, 42 thromboembolic events occurred in 39 patients (23 minor; 14 major; three reversible ischemic neurologic deficits (RIND); two thrombosis). After AVR, the late TE rate was 2.1% per pt-yr, and the major rate 0.6% per pt-yr (exclusive of thrombosis). The overall TE rate after AVR was 2.9% per pt-yr (major rate 1% per pt-yr). After MVR, 25 events occurred in 24 patients (10 minor; eight major; five RIND; two thrombosis). After MVR, the late TE rate was 2.6% per pt-yr, and the major rate 0.7% per pt-yr (exclusive of thrombosis). The overall TE rate after MVR was 3.5% per pt-yr (major rate 1.1% per pt-yr). There were four cases of structural valve deterioration (SVD) (two each after AVR and MVR). Reoperation was performed in three of four cases of thrombosis, and in two of four cases of SVD., Conclusion: The Medtronic Mosaic porcine bioprosthesis is safe and effective. The rate of SVD after six years was low, being zero in the aortic position of patients aged >60 years, and zero also in the mitral position of patients aged <60 years. The incidence of early and late thromboembolism was contributed to by the advanced age of the patient population.

Background and Aim of the Study: The study aim was to characterize changes in mitral valve area and flow, and left ventricular (LV) size and function, following edge-to-edge (E-E) repair for severe functional mitral regurgitation (MR). The possibility that preoperative dobutamine stress echocardiography (DSE) might be used to predict post-repair recovery in LV function was also examined., Methods: Seventeen patients underwent preoperative transthoracic echocardiography (TTE) and DSE, intraoperative transesophageal echocardiography, and three-month postoperative TTE., Results: After repair, mitral valve area was reduced from 8.5 +/- 1.9 cm2 to 3.8 +/- 0.9 cm2 by planimetry (p < 0.0001) and to 2.9 +/- 0.9 cm2 by pressure half-time. Valve area by pressure half-time correlated with the planimetered area (r = +0.55), but was consistently lower (p = 0.004). Sixxteen of 17 patients had mean transmitral gradients <5 mmHg. Postoperative LV end-diastolic diameter improved from 72 +/- 11 to 64 +/- 10 mm (p < 0.01), and end-systolic diameter from 56 +/- 14 to 46 +/- 12 mm (p < 0.05). Mean ejection fraction improved from 25 +/- 12% before repair to 38 +/- 17% after repair (p < 0.02) in patients with evidence of LV function improvement on DSE, but was unchanged (15 +/- 5% versus 17 +/- 5%, p = NS) in patients without evidence of improvement. Postoperatively, 13 patients had no or mild MR, and two patients had moderate MR. There was one perioperative death., Conclusion: E-E repair, in combination with ring annuloplasty, reduces LV cavity dimensions and functional MR severity, without causing significant valve stenosis. Improvement on DSE may predict those patients in whom EF will improve following repair.