Search

Background: Aortic valve sparing operations were introduced three decades ago but controversy remains regarding its appropriateness, reproducibility and durability. This article describes the long-term outcomes of patients who had reimplantation of the aortic valve., Methods: All patients who had reimplantation of a tricuspid aortic valve at Toronto General Hospital from 1989 through 2019 were selected for this study. Patients were followed prospectively with periodical clinical assessments and imaging of the heart and aorta., Results: Four hundred and four patients were identified. The median age was 48.0 [interquartile range (IQR), 35.0-59.0] years and 310 (76.7%) were men. There were 150 patients with Marfan syndrome, 20 with Loeys-Dietz syndrome and 33 with acute or chronic aortic dissections. The median follow-up was 11.7 (IQR, 6.8-17.1) years. There were 55 patients alive and without reoperation at 20 years. The cumulative mortality at 20 years was 26.7% [95% confidence interval (CI): 20.6-34.2%], the cumulative incidence of reoperation on the aortic valve was 7.0% (95% CI: 4.0-12.2%) and the development of moderate or severe aortic insufficiency was 11.8% (95% CI: 8.5-16.5%). We could not identify variables associated with reoperation on the aortic valve or with the development of aortic insufficiency. New distal aortic dissections were common in patients with associated genetic syndromes., Conclusions: Reimplantation of the aortic valve in patients with tricuspid aortic valve provides excellent aortic valve function during the first two decades of follow-up. Distal aortic dissections are relatively common in patients with associated genetic syndromes., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2023 Annals of Cardiothoracic Surgery. All rights reserved.)

Objective: To derive and validate models to predict the risk of a cardiac readmission within one year after specific cardiac surgeries using information that is commonly available from hospital electronic medical records., Methods: In this retrospective cohort study, we derived and externally validated clinical models to predict the likelihood of cardiac readmissions within one-year of isolated CABG, AVR, and combined CABG+AVR in Ontario, Canada, using multiple clinical registries and routinely collected administrative databases. For all adult patients who underwent these procedures, multiple Fine and Gray subdistribution hazard models were derived within a competing-risk framework using the cohort from April 2015 to March 2018 and validated in an independent cohort (April 2018 to March 2020)., Results: For the model that predicted post-CABG cardiac readmission, the c-statistic was 0.73 in the derivation cohort and 0.70 in the validation cohort at one-year. For the model that predicted post-AVR cardiac readmission, the c-statistic was 0.74 in the derivation and 0.73 in the validation cohort at one-year. For the model that predicted cardiac readmission following CABG+AVR, the c-statistic was 0.70 in the derivation and 0.66 in the validation cohort at one-year., Conclusions: Prediction of one-year cardiac readmission for isolated CABG, AVR, and combined CABG+AVR can be achieved parsimoniously using multidimensional data sources. Model discrimination was better than existing models derived from single and multicenter registries., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 Published by Elsevier Inc.)

Background: Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR., Methods: We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020)., Results: The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts., Interpretation: Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions., Competing Interests: Competing interests: Louise Sun received support from the Canadian Institutes of Health Research (CIHR) for article processing charges. Dr. Sun was named National New Investigator by the Heart and Stroke Foundation of Canada, and is supported by a Clinical Research Chair in Big Data and Cardiovascular Outcomes at the University of Ottawa. Douglas Lee is the Ted Rogers Chair in Heart Function Outcomes, University Health Network, University of Toronto. Dr. Lee also received a research grant from CorHealth Ontario and a foundation grant from the Canadian Institutes of Health Research (CIHR). Peter Austin is supported by a Mid-Career Investigator Award from the Heart and Stroke Foundation. Dr. Austin also reports receiving a CIHR Project Grant, paid to Sunnybrook Research Institute. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

Objectives: We sought to evaluate the early outcomes of patients undergoing a Bentall procedure after previous cardiac surgery., Methods: From 1990 to 2014, 473 patients underwent a Bentall procedure after previous cardiac surgery with a composite valve graft at a single institution: composite valve graft with a mechanical prosthesis (n = 256) or composite valve graft with a bioprosthesis (n = 217). Patients were excluded if their index operation was less than 30 days before the reoperation. The primary outcome was 30-day mortality. The secondary outcome was a composite of major morbidity and operative mortality: stroke, renal failure, prolonged mechanical ventilation, deep sternal infection, or reoperation during the same admission. Multivariable logistic regression was used to identify risk factors associated with the primary and secondary outcomes of interest., Results: Median age was 57 (interquartile range, 44-67) years, and 349 patients (74%) were male. Median time between index surgery and reoperation was 13 (interquartile range, 8-21) years. A total of 178 patients (38%) underwent urgent or emergency intervention, 61 patients (13%) had active endocarditis/abscess, 87 patients (19%) had left ventricular ejection fraction less than 40%, and 262 patients (55%) had undergone more than 1 previous operation. Previous operations (not mutually exclusive) included coronary artery bypass grafting (n = 58, 12%), aortic valve/root replacement (n = 376, 80%) or repair (n = 36, 8%), and other surgical interventions (n = 245, 52%). Ninety-six patients (20%) had undergone coronary reimplantation during the previous operation, which consisted of a Bentall procedure in 81 patients, a Ross operation in 8 patients, a valve-sparing root replacement in 4 patients, and an arterial switch in 3 patients. At the time of the reoperative Bentall, both coronary arteries were reimplanted directly in 357 patients (77%), whereas 79 patients (17%) received at least 1 interposition graft. In 26 patients (5%), at least 1 of the native coronary arteries was oversewn and a vein graft bypass was performed. Thirty-day mortality occurred in 37 patients (7.8%), and 152 patients (32%) had major morbidity and operative mortality. On multivariable analysis, risk factors associated with increased 30-day mortality included older age and coronary reimplantation by a technique other than direct anastomosis. Indirect coronary reimplantation was also associated with a higher incidence of major morbidity and operative mortality, as were more than 1 previous cardiac operation and preoperative New York Heart Association functional class III/IV or greater., Conclusions: In the largest reported cohort of aortic root replacement after previous cardiac surgery, the reoperative Bentall procedure was associated with a significant operative risk. The need for complex coronary reimplantation techniques was an important factor associated with adverse perioperative events., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To examine the late outcomes of reimplantation of the aortic valve (RAV) in patients followed prospectively since surgery., Methods: All 465 patients who had RAV from 1989 to 2018 were followed prospectively with periodic clinical and echocardiographic assessments. Mean follow-up was 10 ± 6 years and 98% complete., Results: Patients' mean age was 47 ± 5.1 years, and 78% were men. The aortic root aneurysm was associated with Marfan syndrome in 164 patients, Loeys-Dietz syndrome in 13, bicuspid aortic valve (BAV) in 67, and type A aortic dissection in 33. Aortic insufficiency (AI) was greater than mild in 298 patients. Concomitant procedures were performed in 105 patients. There were 5 operative and 51 late deaths. At 20 years, 69.1% of patients were alive and free from aortic valve reoperation, and the cumulative probability of aortic valve reoperation with death as a competing risk was 6.0%, and the cumulative probability of developing moderate or severe AI was 10.2%. Only time per 1-year interval was associated with the development of postoperative AI by multivariable analysis (hazard ratio, 1.06; 95% confidence interval, >1.02-1.10; P = .006). Gradients across preserved BAV increased in 5 patients, and 1 required reoperation for aortic stenosis. Distal aortic dissections occurred in 22 patients, primarily in those with associated genetic syndromes., Conclusions: RAV provides excellent long-term results, but there is a progressive rate of AI over time, and patients with BAV may develop aortic stenosis. Patients with genetic syndromes have a risk of distal aortic dissections. Continued surveillance after RAV is necessary., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to compare the outcomes of patients undergoing aortic valve-sparing root replacement with bicuspid versus tricuspid aortic valves., Methods: A total of 333 consecutive patients (bicuspid aortic valve, n = 45; tricuspid aortic valve, n = 288) underwent valve-sparing root replacement using the reimplantation technique from 1988 to 2012 at a single institution. The primary analysis was performed on a 1:3 bicuspid aortic valve:tricuspid aortic valve propensity-matched dataset to mitigate known differences between these 2 groups. In the matched, dataset, mean age (bicuspid aortic valve: 40 ± 13 years; tricuspid aortic valve: 41 ± 14) and rates of comorbidities were similar between groups. Patients with bicuspid aortic valves were less likely to have Marfan syndrome (bicuspid aortic valve: 9% vs tricuspid aortic valve: 53%, P < .001). Patients were followed prospectively with aortic root imaging for a median of 8.2 (5.3-12.2) years., Results: Primary cusp repair was required more often in patients with bicuspid aortic valves (bicuspid aortic valve: 79% vs tricuspid aortic valve: 45%, P < .001). A total of 3 operative deaths occurred (bicuspid aortic valve 0% vs tricuspid aortic valve 2%, P = .52). The probability of aortic insufficiency increased significantly over time in both groups (odds ratio, 1.106; 95% confidence interval, 1.033-1.185; P = .004), but there was no significant difference in this increase between the bicuspid aortic valve and tricuspid aortic valve groups (P = .08). Long-term freedom from mortality (P = .20), cumulative incidence of aortic valve reoperation (P = .42), and valve-related events (P = .69) were similar across groups., Conclusions: In well-selected patients with bicuspid aortic valves and favorable cusp morphology, valve-sparing root replacement offers excellent long-term clinical outcomes., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Bicuspid aortic valve (BAV) is the most common congenital cardiac pathology which results from the fusion of two adjacent aortic valve cusps. It is associated with dilatation of the aorta, known as bicuspid valve-associated aortopathy or bicuspid aortopathy. Bicuspid aortopathy is progressive and is linked with adverse clinical events. Hence, frequent monitoring and early intervention with prophylactic surgical resection of the proximal aorta is often recommended. Over the past two decades resection strategies and surgical interventions have mainly been directed by surgeon and institution preferences. These practices have ranged from conservative to aggressive approaches based on aortic size and growth criteria. This strategy, however, may not best reflect the risks of important aortic events. A new set of guidelines was proposed for the treatment of bicuspid aortopathy. Herein, we will highlight the most recent findings pertinent to bicuspid aortopathy and its management in the context of a case presentation.

Objective: Whether the aortopathy associated with bicuspid aortic valve (BAV) disease occurs secondary to genetic or hemodynamic factors remains controversial. In this article we describe the natural history of the aortic root in patients with bicuspid versus tricuspid aortic valves (TAVs) after replacement of the aortic valve and ascending aorta., Methods: From 1990 to 2010, 406 patients (269 BAV, 137 TAV) underwent aortic valve and ascending aorta replacement at a single institution. Patients with aortic dissection, endocarditis, previous aortic surgery, or Marfan syndrome were excluded. All available follow-up imaging was reviewed., Results: Mean imaging follow-up was 5.5 (±5.3) years. Of all patients, 66.5% had at least 1 aortic root measurement after the index operation. Baseline aortic diameter was comparable between groups. In patients with BAV, aortic root diameter increased at a clinically negligible rate over time (0.654 mm per year; 95% confidence interval, 0.291-1.016; P < .001), similar to patients with TAV (P = .92). Mean clinical follow-up was 8.1 (±5.4) years. During follow-up, 18 patients underwent reoperation, 89% for a degenerated bioprosthetic aortic valve. Only 1 patient underwent reoperation for a primary indication of aortic aneurysmal disease, 22 years after the index operation. There were no differences in cumulative incidence rates of aortic reoperation (P = .14) between patients with BAV and TAV., Conclusions: Mid-term imaging after aortic valve and ascending aorta replacement indicates that if the aortic root is not dilated at the time of surgery, the risk of enlargement over time is minimal, negating the need for prophylactic root replacement in patients with BAV or TAV., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical aortic root enlargement (ARE) during aortic valve replacement (AVR) allows for larger prosthesis implantation and may be an important adjunct to surgical AVR in the transcatheter valve-in-valve era. The incremental operative risk of adding ARE to AVR has not been established. We aimed to evaluate the early outcomes of patients undergoing AVR with or without ARE., Methods: From January 1990 to August 2014, 7039 patients underwent AVR (AVR+ARE, n=1854; AVR, n=5185) at a single institution. Patients with aortic dissection and active endocarditis were excluded. Mean age was 65±14 years and 63% were male. Logistic regression and propensity score matching were used to adjust for unbalanced variables in group comparisons., Results: Patients undergoing AVR+ARE were more likely to be female (46% versus 34%, P <0.001) and had higher rates of previous cardiac surgery (18% versus 12%, P <0.001), chronic obstructive pulmonary disease (5% versus 3%, P =0.004), urgent/emergent status (6% versus 4%, P =0.01), and worse New York Heart Association status ( P <0.001). Most patients received bioprosthetic valves (AVR+ARE: 73.4% versus AVR: 73.3%, P =0.98) and also underwent concomitant cardiac procedures (AVR+ARE: 68% versus AVR: 67%, P =0.31). Mean prosthesis size implanted was slightly smaller in patients requiring AVR+ARE versus AVR (23.4±2.1 versus 24.1±2.3, P <0.001). In-hospital mortality was higher after AVR+ARE (4.3% versus 3.0%, P =0.008), although when the cohort was restricted to patients undergoing isolated aortic valve replacement with or without root enlargement, mortality was not statistically different (AVR+ARE: 1.7% versus AVR: 1.1%, P =0.29). After adjustment for baseline characteristics, AVR+ARE was not associated with an increased risk of in-hospital mortality when compared with AVR (odds ratio, 1.03; 95% confidence interval, 0.75-1.41; P =0.85). Furthermore, AVR+ARE was not associated with an increased risk of postoperative adverse events. Results were similar if propensity matching was used instead of multivariable adjustments for baseline characteristics., Conclusions: In the largest analysis to date, ARE was not associated with increased risk of mortality or adverse events. Surgical ARE is a safe adjunct to AVR in the modern era., (© 2017 American Heart Association, Inc.)

Management of cardiac surgery health human resources (HHR) has been challenging, with recent graduates struggling to secure employment and a shortage of cardiac surgeons predicted as early as 2020. The length of cardiac surgery training prevents HHR supply from adapting in a timely fashion to changes in demand, resulting in a critical need for active workforce management. This study details the results of the 2015 Canadian Society of Cardiac Surgeons (CSCS) workforce survey undertaken as part of the CSCS strategy for active workforce management. The 38-question survey was administered electronically to all 96 trainees identified as being registered in a Canadian cardiac surgery residency program for the 2015-2016 academic year. Eighty-four of 96 (88%) trainees responded. The majority of participants were satisfied with their training experience. However, 29% stated that their clinical and operative exposure needed improvement, and 57% of graduating trainees did not believe that they would be competent to practice independently at the conclusion of their training. Although 51% of participants believe the job market is improving, 94% of senior trainees found it competitive or extremely difficult to secure an attending staff position. Participants highlighted a need for improved career counselling and formal mentorship. Although the job market is perceived to be improving, a mismatch in the cardiac surgery workforce supply and demand remains because current trainees continue to experience difficulty securing employment after the completion of residency training. Trainees have identified improved career counselling and mentorship as potential strategies to aid graduates in securing employment., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objective: To provide additional information on clinical and echocardiographic outcomes after reimplantation of the aortic valve (RAV) in patients with aortic root aneurysm., Methods: All 333 patients who underwent RAV at our hospital between 1989 and 2012 were followed prospectively with periodical clinical assessment and echocardiography. The mean duration of clinical follow-up was 10.3 ± 6.8 years, and follow-up was completed within 2 years before this report., Results: The study cohort had a mean patient age was 46 ± 5 years and was 78% male. The aortic root aneurysm was associated with Marfan syndrome in 124 patients, with bicuspid aortic valve in 45, with type A aortic dissection in 28, and with moderate to severe aortic regurgitation (AR) in 144. In addition to the RAV, 113 patients underwent another cardiac procedure owing to associated pathology. There were 4 early deaths (<90 days) and 35 late deaths. Survival at 15 and 20 years was 77.9 ± 2.9% and 72.4 ± 3.8%, respectively. Eleven patients developed moderate or severe AR during the follow-up; using interval censoring, 96.2 ± 1.0% were free from this event at 15 to 20 years. Six patients underwent reoperation on the aortic valve at 2 days to 23 years after RAV, including 1 patient for endocarditis and 5 patients for AR; freedom from reoperation at 15 to 20 years was 96.9 ± 1.3%. Seventeen patients sustained stroke or transient ischemic attacks; 92.5 ± 2.8% were free from thromboembolism at 15 and 20 years. Three patients developed infective endocarditis: 1 in the aortic valve and 2 in the mitral valve., Conclusions: RAV continues to provide excellent clinical results and stable aortic valve function during the second decade of observation., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Although aortic valve-sparing (AVS) operations are established alternatives to composite valve graft (CVG) procedures for patients with aortic root aneurysms, comparative long-term outcomes are lacking., Objectives: This study sought to compare the results of patients undergoing AVS procedures with those undergoing CVG operations., Methods: From 1990 to 2010, a total of 616 patients age <70 years and without aortic stenosis underwent elective aortic root surgery (AVS, n = 253; CVG with a bioprosthesis [bio-CVG], n = 180; CVG with a mechanical prosthesis [m-CVG], n = 183). A propensity score was used as a covariate to adjust for unbalanced variables in group comparisons. Mean age was 46 ± 14 years, 83.3% were male, and mean follow-up was 9.8 ± 5.3 years., Results: Patients undergoing AVS had higher rates of Marfan syndrome and lower rates of bicuspid aortic valve than those undergoing bio-CVG or m-CVG procedures. In-hospital mortality (0.3%) and stroke rate (1.3%) were similar among groups. After adjusting for clinical covariates, both bio-CVG and m-CVG procedures were associated with increased long-term major adverse valve-related events compared with patients undergoing AVS (hazard ratio [HR]: 3.4, p = 0.005; and HR: 5.2, p < 0.001, respectively). They were also associated with increased cardiac mortality (HR: 7.0, p = 0.001; and HR: 6.4, p = 0.003). Furthermore, bio-CVG procedures were associated with increased risk of reoperations (HR: 6.9; p = 0.003), and m-CVG procedures were associated with increased risk of anticoagulant-related hemorrhage (HR: 5.6; p = 0.008) compared with AVS procedures., Conclusions: This comparative study showed that AVS procedures were associated with reduced cardiac mortality and valve-related complications when compared with bio-CVG and m-CVG. AVS is the treatment of choice for young patients with aortic root aneurysm and normal or near-normal aortic cusps., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Although the appropriate use criteria incorporate common clinical scenarios for coronary revascularization, a significant proportion of patients with stable coronary artery disease (CAD) cannot be assigned an appropriateness score. Our objective was to characterize these patients and to evaluate whether coronary revascularization is associated with improved outcomes. A population-based cohort of patients aged ≥66 years, who underwent cardiac catheterization in Ontario, Canada, were included. Clinical characteristics were compared between patients with and without an appropriateness score. Clinical outcomes between coronary revascularization and medical therapy in patients with unclassified appropriateness score were compared using the inverse probability of treatment-weighted propensity method for confounder adjustment. Of the 19,228 patients with stable CAD, 11.2% (2,153 patients) were not assigned to an appropriateness score, mostly (92.9%) because of a lack of ischemic evaluation or a noninterpretable test. These patients were older, had higher rate of severe angina, and had more medical co-morbidities compared to patients with an appropriateness score. The 2-year rate of death or myocardial infarction in patients with unclassified appropriateness score was 15.3% in the revascularization group versus 20.7% in the medical therapy group. After propensity weighting, revascularization was associated with significantly lower hazard ratio (0.70; 95% confidence interval 0.61 to 0.79) for death or myocardial infarction compared with medical therapy. In conclusion, in patients aged ≥66 years with stable CAD and unclassified appropriateness score, revascularization is associated with improved outcomes., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Impaired left ventricular (LV) myocardial deformation is associated with adverse outcome in patients with severe aortic stenosis (AS). The aim of this retrospective study was to assess the impact of transcatheter aortic valve implantation (TAVI) on the recovery of myocardial mechanics and the influence of postprocedural aortic regurgitation (AR)., Methods: Speckle-tracking echocardiography was used to assess multidirectional myocardial deformation (longitudinal and circumferential strain) and rotational mechanics (apical rotation and twist) before and at midterm follow-up after TAVI. Predictors of myocardial recovery, defined as a ≥20% relative increase in the magnitude of global longitudinal strain compared with baseline, were examined., Results: Sixty-four patients (median age, 83 years; interquartile range, 77-86 years) with severe AS and high surgical risk (mean European System for Cardiac Operative Risk Evaluation score, 20 ± 13%) were evaluated. Overall, LV longitudinal deformation was impaired at baseline compared with controls. At 5 ± 3 months after TAVI, LV longitudinal deformation had significantly improved only in the group of patients with baseline LV ejection fractions (LVEF) ≤ 55%: global longitudinal strain from -9.7 ± 3.7% to -11.8 ± 3.2% (P = .05), longitudinal strain rate from -0.44 ± 0.14 sec(-1) to -0.57 ± 0.16 sec(-1) (P = .001), and early diastolic strain rate from 0.38 ± 0.17 sec(-1) to 0.49 ± 0.18 sec(-1) (P = .01). In patients with normal LVEFs, LV twist was supraphysiologic at baseline and normalized after TAVI (from 16.1 ± 6.9° to 11.9 ± 6.2°, P = .004). In patients with baseline LVEFs ≤ 55%, circumferential deformation was impaired before TAVI and improved after TAVI. Baseline LVEF (odds ratio, 0.56 per 10% increment; P = .02) and global longitudinal strain (odds ratio, 0.65 per absolute 1% increment; P < .001) were significant predictors of myocardial recovery. LV mass, volumes, and longitudinal strain failed to favorably remodel in patients with post-TAVI important AR (defined as new mild post-TAVI AR or moderate or severe post-TAVI AR [either preexisting or new AR])., Conclusions: TAVI restores LV function toward more physiologic myocardial mechanics in both normal- and depressed-LVEF groups. Patients with lower systolic function derive the most benefit in terms of longitudinal reverse remodeling. Postprocedural AR adversely affects LV structural and functional remodeling., (Copyright © 2014 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the late outcomes of aortic valve-sparing operations to treat patients with aortic root aneurysm with and without aortic insufficiency (AI) in a cohort of patients followed up prospectively since 1988., Methods: A total of 371 consecutive patients had undergone aortic valve-sparing surgery (mean age, 47 ± 15 years; 78% men) from 1988 through 2010. In addition to the aortic root aneurysm, 47% had moderate or severe AI, 35.5% had Marfan syndrome, 12.1% had type A aortic dissection, 9.2% had bicuspid aortic valve, 8.4% had mitral insufficiency, 16.1% had aortic arch aneurysm, and 10.2% had coronary artery disease. Reimplantation of the aortic valve was used in 296 patients and remodeling of the aortic root in 75. Cusp repair by plication of the free margin along the nodule of Arantius was used in 36.6% of patients, and reinforcement of the free margin with a double layer of fine Gore-Tex suture in 24.2%. The patients were followed up prospectively with images of the aortic root for a median follow-up of 8.9 ± 5.2 years., Results: A total of 4 operative and 39 late deaths occurred. Survival at 18 years was 76.8% ± 4.31%, lower than that for the general population matched for age and gender. Age, type A aortic dissection, impaired ventricular function, and preoperative AI were associated with increased mortality on multivariable analysis. Reoperations on the aortic valve were performed in 8 patients for recurrent AI and in 2 for infective endocarditis. Freedom from reoperation on the aortic valve at 18 years was 94.8% ± 2.0%. No predictors of the need for reoperation were found on multivariable analysis. Eighteen patients developed AI greater than mild. Freedom from AI greater than mild at 18 years was 78.0% ± 4.8%. No predictors of recurrent AI were identified on multivariable analysis., Conclusions: Aortic valve-sparing operations continue to provide excellent clinical outcomes, although a slow but progressive deterioration of aortic valve function seems to occur during the first 2 decades of follow-up. Preoperative AI and cusp repair had no adverse effect on valve function., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Coronary angiograms are important in the diagnostic workup of patients with suspected coronary artery disease. However, little is known about the clinical predictors of normal angiograms and whether this rate varies across different cardiac centers in Ontario., Methods: We conducted a study using the Cardiac Care Network Variations in Revascularization Practice in Ontario database of 2,718 patients undergoing an index cardiac catheterization for an indication of stable angina between April 2006 and March 2007 at one of 17 cardiac hospitals in Ontario. We determined predictors of normal coronary angiograms (0% coronary stenosis) and compared rates of patients with normal catheterizations across centers., Results: Overall, 41.9% of patients with stable angina had a normal catheterization. A multivariate model demonstrated female gender to be the strongest predictor of a normal angiogram (odds ratio 3.55, 95% CI 2.93-4.28). In addition, atypical ischemic symptoms or no symptoms, the absence of diabetes, hyperlipidemia, smoking history, peripheral vascular disease, and angiography performed at a nonteaching site were associated with higher rates of normal catheterization. The rate of normal angiograms studied varied from 18.4% to 76.9% across hospitals and was more common in community compared with academic settings (47.1% vs 35.4%, P < .001)., Conclusions: The absence of traditional cardiac risk factors, female gender, and lack of typical angina symptoms are all associated with a higher frequency of normal cardiac catheterizations. The wide variation in Ontario in the frequency of normal angiograms in patients with stable angina suggests that there are opportunities to improve patient case selection., (© 2013 Mosby, Inc. All rights reserved.)

Objectives: Aortic valve sparing is frequently performed to treat patients with aortic root aneurysm, but there is an inadequate amount of information regarding its long-term durability. This study examines the long-term results of reimplantation of the aortic valve in patients with aortic root aneurysms., Methods: From August 1989 to December 2010, 296 consecutive patients had reimplantation of the aortic valve into a tubular Dacron graft. Their mean age was 45 years (range, 11-79 years), and 78% were men. Of the patients, 36% had Marfan syndrome and 11% had bicuspid aortic valve. Patients were followed prospectively with periodic images of the aortic root and remaining aorta. The mean follow-up was 6.9 ± 4.5 years. There were 21 patients at risk at 15 years., Results: There were 4 operative and 18 late deaths. The survival at 5, 10, and 15 years was 95.1% ± 3.5%, 93.1% ± 4.4%, and 76.5% ± 18%, respectively. Only 3 patients required reoperation on the aortic valve; all 3 patients had the Bentall procedure. Freedom from reoperation at 5, 10, and 15 years was 99.7% ± 2.0%, 97.8% ± 5.3%, and 97.8% ± 5.3%, respectively. During follow-up, moderate aortic insufficiency developed in 9 patients, and severe aortic insufficiency developed in 2 patients. Freedom from moderate or severe aortic insufficiency at 5, 10, and 15 years was 98.3% ± 3.5%, 92.9% ± 6.5%, and 89.4% ± 12%, respectively., Conclusions: The function of the aortic valve implanted inside a tubular Dacron graft remains normal at 15 years in most patients after this type of aortic valve-sparing operation., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The only effective treatment for severe aortic stenosis (AS) is valve replacement. However, many patients with co-existing conditions are ineligible for surgical valve replacement, historically leaving medical management (MM) as the only option which has a poor prognosis. Transcatheter Aortic Valve Replacement (TAVR) is a less invasive replacement method. The objective was to estimate cost-effectiveness of TAVR via transfemoral access vs MM in surgically inoperable patients with severe AS from the Canadian public healthcare system perspective., Methods: A cost-effectiveness analysis of TAVR vs MM was conducted using a deterministic decision analytic model over a 3-year time horizon. The PARTNER randomized controlled trial results were used to estimate survival, utilities, and some resource utilization. Costs included the valve replacement procedure, complications, hospitalization, outpatient visits/tests, and home/nursing care. Resources were valued (2009 Canadian dollars) using costs from the Ontario Case Costing Initiative (OCCI), Ontario Ministry of Health and Long-Term Care and Ontario Drug Benefits Formulary, or were estimated using relative costs from a French economic evaluation or clinical experts. Costs and outcomes were discounted 5% annually. The effect of uncertainty in model parameters was explored in deterministic and probabilistic sensitivity analysis., Results: The incremental cost-effectiveness ratio (ICER) was $32,170 per quality-adjusted life year (QALY) gained for TAVR vs MM. When the time horizon was shortened to 24 and 12 months, the ICER increased to $52,848 and $157,429, respectively. All other sensitivity analysis returned an ICER of less than $50,000/QALY gained., Limitations: A limitation was lack of availability of Canadian-specific resource and cost data for all resources, leaving one to rely on clinical experts and data from France to inform certain parameters., Conclusions: Based on the results of this analysis, it can be concluded that TAVR is cost-effective compared to MM for the treatment of severe AS in surgically inoperable patients.

A 45-year-old female underwent heart transplantation 17 years ago, with a heart from a 15-year-old donor. Recently, she had developed an aneurysm of the donor aortic root and ascending aorta, with severe aortic insufficiency. Two surgical options were considered; retransplantation versus replacement of the aortic root and ascending aorta. A valve-sparing replacement of the aortic root and ascending aortic aneurysm was performed. The donor aorta showed pathologic changes typical of Marfan syndrome. Nineteen months postoperatively, the patient remains in functional class I, with trivial aortic insufficiency., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to evaluate the long-term outcomes after transcatheter aortic valve implantation (TAVI) in the Multicenter Canadian Experience study, with special focus on the causes and predictors of late mortality and valve durability., Background: Very few data exist on the long-term outcomes associated with TAVI., Methods: This was a multicenter study including 339 patients considered to be nonoperable or at very high surgical risk (mean age: 81 ± 8 years; Society of Thoracic Surgeons score: 9.8 ± 6.4%) who underwent TAVI with a balloon-expandable Edwards valve (transfemoral: 48%, transapical: 52%). Follow-up was available in 99% of the patients, and serial echocardiographic exams were evaluated in a central echocardiography core laboratory., Results: At a mean follow-up of 42 ± 15 months 188 patients (55.5%) had died. The causes of late death (152 patients) were noncardiac (59.2%), cardiac (23.0%), and unknown (17.8%). The predictors of late mortality were chronic obstructive pulmonary disease (hazard ratio [HR]: 2.18, 95% confidence interval [CI]: 1.53 to 3.11), chronic kidney disease (HR: 1.08 for each decrease of 10 ml/min in estimated glomerular filtration rate, 95% CI: 1.01 to 1.19), chronic atrial fibrillation (HR: 1.44, 95% CI: 1.02 to 2.03), and frailty (HR: 1.52, 95% CI: 1.07 to 2.17). A mild nonclinically significant decrease in valve area occurred at 2-year follow-up (p < 0.01), but no further reduction in valve area was observed up to 4-year follow-up. No changes in residual aortic regurgitation and no cases of structural valve failure were observed during the follow-up period., Conclusions: Approximately one-half of the patients who underwent TAVI because of a high or prohibitive surgical risk profile had died at a mean follow-up of 3.5 years. Late mortality was due to noncardiac comorbidities in more than one-half of patients. No clinically significant deterioration in valve function was observed throughout the follow-up period., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The study assessed the appropriateness of coronary revascularization in Ontario, Canada, and examined its association with longer-term outcomes., Background: Although appropriate use criteria for coronary revascularization have been developed to improve the rational use of cardiac invasive procedures, it is unknown whether greater adherence to appropriateness guidelines is associated with improved clinical outcomes in stable coronary artery disease., Methods: A population-based cohort of stable patients undergoing cardiac catheterization was assembled from April 1, 2006, to March 31, 2007. The appropriateness for coronary revascularization at the time of coronary angiography was retrospectively adjudicated using the appropriate use criteria. Clinical outcomes between coronary revascularization and medical treatment without revascularization, stratified by appropriateness categories, were compared., Results: In 1,625 patients with stable coronary artery disease, percutaneous coronary intervention or coronary artery bypass grafting was only performed in 69% who had an appropriate indication for coronary revascularization. Coronary revascularization was associated with a lower adjusted hazard of death or acute coronary syndrome (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.42 to 0.88) at 3 years compared with medical therapy in appropriate patients. The rate of coronary revascularization was 54% in the uncertain category and 45% in the inappropriate category. No significant difference in death or acute coronary syndrome between coronary revascularization and no revascularization in the uncertain category (HR: 0.57; 95% CI: 0.28 to 1.16) and the inappropriate category (HR: 0.99; 95% CI: 0.48 to 2.02) was observed., Conclusions: Using the appropriateness use criteria, we identified substantial underutilization and overutilization of coronary revascularization in contemporary clinical practice. Underutilization of coronary revascularization is associated with significantly increased risks of adverse outcomes in patients with appropriate indications., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

As the professional society representing cardiac surgeons in Canada, the Canadian Society of Cardiac Surgeons (CSCS) recognizes the importance of maintaining a stable cardiac surgical workforce. The current reactive approach to health human resource management in cardiac surgery is inadequate and may result in significant misalignment of cardiac surgeon supply and demand. The availability of forecasting models and high quality, consistent data on productivity, workload, utilization, and demand is a prerequisite for our profession's capacity to predict and plan for changes in health human resources. The CSCS recognizes that improved workforce management is a key component to providing optimal cardiac surgical care for Canadians in the future and has developed the recommendations in this document as a call to action to interested stakeholders and policymakers to bring substantial improvements to health human resource management in cardiac surgery., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The ratio of percutaneous coronary interventions to coronary artery bypass graft surgeries (PCI:CABG ratio) varies considerably across hospitals. We conducted a comprehensive study to identify clinical and nonclinical factors associated with variations in the ratio across 17 cardiac centres in the province of Ontario., Methods: In this retrospective cohort study, we selected a population-based sample of 8972 patients who underwent an index cardiac catheterization between April 2006 and March 2007 at any of 17 hospitals that perform invasive cardiac procedures in the province. We classified the hospitals into four groups by PCI:CABG ratio (low [< 2.0], low-medium [2.0-2.7], medium-high [2.8-3.2] and high [> 3.2]). We explored the relative contribution of patient, physician and hospital factors to variations in the likelihood of patients receiving PCI or CABG surgery within 90 days after the index catheterization., Results: The mean PCI:CABG ratio was 2.7 overall. We observed a threefold variation in the ratios across the four hospital ratio groups, from a mean of 1.6 in the lowest ratio group to a mean of 4.6 in the highest ratio group. Patients with single-vessel disease usually received PCI (88.4%-99.0%) and those with left main artery disease usually underwent CABG (80.8%-94.2%), regardless of the hospital's procedure ratio. Variation in the management of patients with non-emergent multivessel disease accounted for most of the variation in the ratios across hospitals. The mode of revascularization largely reflected the recommendation of the physician performing the diagnostic catheterization and was also influenced by the revascularization "culture" at the treating hospital., Interpretation: The physician performing the diagnostic catheterization and the treating hospital were strong independent predictors of the mode of revascularization. Opportunities exist to improve transparency and consistency around the decision-making process for coronary revascularization, most notably among patients with non-emergent multivessel disease.

Transcatheter aortic valve implantation (TAVI), via either a femoral or apical approach, has been developed as an alternative to conventional aortic valve replacement for patients whose operative risks are considered too high for conventional surgery. Complications with these relatively new procedures are being reported with increasing frequency. We report a case of transapical TAVI, in which the patient developed a false aneurysm at the apex of the left ventricle as a complication of the procedure., (© 2010 Wiley Periodicals, Inc.)

Background: Limited employment opportunities for recently trained cardiac surgeons are deterring medical students from entering cardiac surgery residency programs. Given the lengthy training period and the aging of both the general population and currently practicing cardiac surgeons, this reduced enrollment raises concerns about the adequacy of the future cardiac surgery workforce. A workforce model was developed to explore the future need for cardiac surgeons in Canada., Methods: A novel system dynamics model was developed to simulate the supply and demand for cardiac surgery in Canada between 2008 and 2030 to identify whether an excess or shortage of surgeons would exist. Several different scenarios were examined, including varying surgeon productivity, revascularization rates, and residency enrollment rates., Results: The simulation results of various scenarios are presented. In the base case, a surgeon shortage is expected to develop by 2025, although this depends on surgeons' response to demand-supply gap changes. An alternative scenario in which residency enrollment directly relates to the presence of unemployed surgeons also projects substantial shortages after 2021. The model results indicate that if residency enrollment rates remain at the 2009 level an alarming shortage may develop soon, possibly reaching almost 50% of the Canadian cardiac surgical workforce., Conclusions: These workforce model results project an eventual cardiac surgeon shortage in Canada. This study highlights the possibility of a crisis in cardiac surgery and emphasizes the urgency with which enrollment into cardiac surgery training programs and the employability of recently trained cardiac surgery graduates need to be addressed., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The number of applications to Canadian cardiac surgery programs has declined recently. Perception of a difficult job market for new graduates may contribute to this decline. The objective of this survey was to document the experience of recent graduates of Canadian cardiac surgery training programs., Methods: A 45-question, web-based survey was distributed to all graduates of Canadian cardiac surgery training programs who completed their training between 2002 and 2008., Results: Of the 62 estimated recent graduates, 50 completed the survey (81%). Mean age was 36 + or - 3 years and 90% were male. The mean number of years of training after medical school was 9.4 + or - 1.6 years; 78% completed a graduate degree; and 27% extended their training because of a lack of jobs. When asked about employment, 74% mostly or definitely got the job they wanted, although 34% considered themselves underemployed. Most respondents (98%) considered finding employment for a new graduate in cardiac surgery today difficult or extremely difficult, and 64% believed that there is currently an excess of cardiac surgeons in Canada. Only 54% of participants would strongly recommend cardiac surgery to potential trainees., Conclusions: The majority of recent graduates from Canadian cardiac surgery training programs were successful in finding secure employment. A substantial proportion, however, extended their training because of a lack of jobs and reported feeling underemployed. Survey respondents agreed that a new graduate might have difficulty finding a job in cardiac surgery today. These concerns may contribute to the challenges of recruiting to the specialty., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was: 1) to evaluate the acute and late outcomes of a transcatheter aortic valve implantation (TAVI) program including both the transfemoral (TF) and transapical (TA) approaches; and 2) to determine the results of TAVI in patients deemed inoperable because of either porcelain aorta or frailty., Background: Very few data exist on the results of a comprehensive TAVI program including both TA and TF approaches for the treatment of severe aortic stenosis in patients at very high or prohibitive surgical risk., Methods: Consecutive patients who underwent TAVI with the Edwards valve (Edwards Lifesciences, Inc., Irvine, California) between January 2005 and June 2009 in 6 Canadian centers were included., Results: A total of 345 procedures (TF: 168, TA: 177) were performed in 339 patients. The predicted surgical mortality (Society of Thoracic Surgeons risk score) was 9.8 +/- 6.4%. The procedural success rate was 93.3%, and 30-day mortality was 10.4% (TF: 9.5%, TA: 11.3%). After a median follow-up of 8 months (25th to 75th interquartile range: 3 to 14 months) the mortality rate was 22.1%. The predictors of cumulative late mortality were peri-procedural sepsis (hazard ratio [HR]: 3.49, 95% confidence interval [CI]: 1.48 to 8.28) or need for hemodynamic support (HR: 2.58, 95% CI: 1.11 to 6), pulmonary hypertension (PH) (HR: 1.88, 95% CI: 1.17 to 3), chronic kidney disease (CKD) (HR: 2.30, 95% CI: 1.38 to 3.84), and chronic obstructive pulmonary disease (COPD) (HR: 1.75, 95% CI: 1.09 to 2.83). Patients with either porcelain aorta (18%) or frailty (25%) exhibited acute outcomes similar to the rest of the study population, and porcelain aorta patients tended to have a better survival rate at 1-year follow-up., Conclusions: A TAVI program including both TF and TA approaches was associated with comparable mortality as predicted by surgical risk calculators for the treatment of patients at very high or prohibitive surgical risk, including porcelain aorta and frail patients. Baseline (PH, COPD, CKD) and peri-procedural (hemodynamic support, sepsis) factors but not the approach determined worse outcomes., (Copyright 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Hypertonic saline (HTS) has been previously demonstrated to have immune modulatory and vascular protective effects. We assessed the effect of donor pretreatment with HTS on allograft preservation in a porcine model of orthotopic heart transplantation., Methods and Results: Orthotopic transplants were performed after 6 hours of cold static allograft storage. Donor pigs were randomly assigned to pretreatment with (n=7) or without (n=6) HTS (4.5 mL/kg of 7.5% NaCl) administered 1 hour before donor heart arrest. Administration of HTS increased serum sodium level from 138+/-2 mmol/L to 154+/-4 mmol/L, which normalized to 144+/-3 mmol/L 1 hour after infusion. Successful weaning from cardiopulmonary bypass was significantly greater in HTS-treated hearts (6/7 vs 1/6; P=0.029). Preload recruitable stroke work after transplantation was improved compared to control (88+/-21% vs 35+/-8% of baseline; P=0.0001). Similarly, end-systolic elastance was improved compared to control (85+/-17% vs 42+/-12% of baseline; P=0.0002). Posttransplantation systolic blood pressure was significantly higher in the donor HTS group (60+/-9 mm Hg vs 35+/-6 mm Hg; P=0.04). Donor HTS treatment improved coronary artery endothelial-dependent vasorelaxation compared with control (Emax: HTS, 59+/-4%; control, 47+/-3%; P=0.04). HTS also resulted in improved endothelial-independent vasorelaxation compared with control (Emax: HTS, 71+/-3%; control, 59+/-4%; P=0.03; ED-50: HTS, 0.56x10 to 6+/-0.23 mol/L; control, 2.5x10 to 6+/-1.0 mol/L; P=0.04). Sensitivity to endothelin-1-induced vasospasm was reduced with HTS pretreatment (% maximum contraction [Cmax]: HTS, 338+/-15%; control, 419+/-40%; P=0.01)., Conclusions: Donor HTS pretreatment attenuates posttransplantation cardiac allograft myocardial dysfunction, improves posttransplantation systemic hemodynamic function, and preserves posttransplantation cardiac allograft vascular function. HTS may be a novel organ donor intervention to prevent primary graft dysfunction.

Objective: In active infective endocarditis the need for operating simultaneously on the aortic and mitral valves is frequent. There are no studies in the literature documenting long-term outcomes of double valve surgery for active endocarditis., Methods: Ninety patients underwent double valve surgery for active endocarditis over a 26-year period (mean age, 53 +/- 16 years; 71% male patients). Prosthetic endocarditis was seen in 32 patients. Staphylococcus species was isolated in 29%. Forty-six (51%) patients had abscesses. Surgical intervention consisted of valve repair or replacement with limited infection or radical resection, patch reconstruction, and valve replacement for abscesses. Mean follow-up was 5.9 +/- 4.7 years (range, 0-18 years) and was complete., Results: There were 14 (15.6%) in-hospital deaths and 29 (32.2%) late deaths. Overall survival at 5, 7, and 10 years was 68% +/- 5%, 59% +/- 6%, and 49% +/- 6%, respectively, and was reduced in those undergoing operations for prosthetic compared with native endocarditis (7-year survival, 39% +/- 9% vs 71% +/- 7%; P < .001). Freedom from recurrent endocarditis was 84% +/- 5% at 10 years. Freedom from reoperation was 91% +/- 4% at 10 years. Event-free survival at 7 and 10 years was 60% +/- 6% and 47% +/- 7%, respectively. No difference was observed between the native and prosthetic groups for recurrent endocarditis, late reoperation, or event-free survival. Prosthetic endocarditis, increasing age, preoperative shock, and diabetes mellitus were independent predictors of death from all causes., Conclusions: Double valve surgery for active endocarditis remains technically challenging and associated with significant morbidity and mortality perioperatively and in the longer term. Outcomes are worse in those who have prosthetic valve endocarditis.

Background: Elderly patients older than the age of 75 constitute 13% of the population that undergoes cardiac surgery at our institution and represent the fastest growing population in Ontario. We have witnessed an increasing proportion of elderly patients being referred for repeat surgical intervention for valvular heart disease. We determined the perioperative and long-term outcomes in elderly patients undergoing redo cardiac valve surgery., Methods: A retrospective review of our institutional database identified 112 patients aged 75 years or older (mean age, 78 +/- 3 years; range, 75 to 89 years) who underwent redo valve surgery between 1990 and 2004. All patients presented with a previous surgical intervention on the valve of interest. The mean follow-up was 5 +/- 4 years and was 100% complete., Results: Eighty-eight patients (79%) had isolated valve surgery at their primary operation whereas 24 patients (21%) had concomitant coronary artery bypass grafting at the time of their initial valve surgery. At reoperation, 74 patients (66%) underwent single valve surgery (40 aortic valve, 34 mitral valve), 33 patients (29.5%) required double valve surgery, and 5 patients (4.5%) had triple valve surgery. Thirty-three patients (29.5%) required concomitant coronary artery bypass grafting, among whom 14 patients had a previous coronary artery bypass graft surgery. There were 12 operative (10.7%) and 47 late deaths (42%). Cardiovascular events were the cause of death in 32 patients (54% of all deaths). Overall survival at 5 years was 67% +/- 5%. The freedom from valve-related mortality and morbidity was 86% +/- 4% at 5 years. Mean intensive care eunit stay was 3.7 +/- 4.5 days, and postoperative hospital stay was 15 +/- 12 days., Conclusions: Redo valvular surgery in an elderly cohort can be performed with acceptable morbidity and mortality. Although 5-year survival is lower than that observed with a younger patient population, it is still likely higher than expected survival without surgical intervention. Despite increased resource utilization, elderly patients should be offered redo surgical intervention for valvular heart disease.

Objective: Rupture of glutaraldehyde-fixed porcine aortic roots has been reported, but the mechanism and incidence of this complication is unknown. This study evaluates the clinical outcomes and the risk of dilation and rupture of porcine aortic roots after implantation., Methods: Commercially available porcine aortic roots were used for aortic root replacement in 308 patients (Freestyle bioprosthesis [Medtronic, Minneapolis, Minn] in 251 patients and Toronto Root [St Jude Medical, St Paul, Minn] in 57 patients) whose mean age was 62 +/- 13 years. The main indication for aortic root replacement was dilation of the native aortic root. Clinical follow-up was complete at a mean of 5.3 +/- 2.5 years. Valve function and aortic root diameter were assessed by means of echocardiography., Results: There were 10 (3.2%) operative and 39 (12.6%) late deaths. At 8 years, patients' survival was 79.0% +/- 3.1%, freedom from reoperation was 95.3% +/- 1.7%, and freedom from severe aortic insufficiency was 93.8% +/- 2.7%. The diameter of the aortic sinuses increased from 31.9 +/- 4.3 to 34.1 +/- 4.8 mm (P < .0001), and it exceeded 40 mm in 10% of the patients. Linear regression analysis revealed that the duration of follow-up (P < .0001) and the size of the valve implanted (P < .0001) were associated with risk of sinus dilation. There was only 1 early rupture of the noncoronary aortic sinus and 2 late aneurysms that required repeat operations. Histologic examination of explanted aneurysmal porcine roots revealed marked changes in the xenograft arterial wall, with abundant mononuclear cells suggestive of immunologic reaction., Conclusions: Mild dilation of porcine aortic roots after aortic root replacement is common, but aneurysm formation and rupture are rare during the first decade of follow-up. Annual surveillance with echocardiography is recommended.

Objective: Although several studies have examined the outcomes of mitral valve repair for infective endocarditis, no studies have documented the long-term outcomes of surgical intervention for active endocarditis confined to the mitral valve., Methods: One hundred four patients underwent surgical intervention for active infective endocarditis confined to the mitral valve over a 27-year period (mean age, 50 +/- 18 years; 52% female). The infected valve was native in 81 patients, previously repaired 6 patients, and prosthetic in 17 patients. Staphylococcus aureus was the most commonly isolated (32%) source of infection. Twenty-eight (27%) patients had annular abscesses. Surgical intervention consisted of valve repair or replacement for limited infection and radical resection, annular patch reconstruction, and valve replacement for annular abscess. Mean follow-up was 5.6 +/- 4.4 years (range, 0-20 years) and was complete., Results: There were 9 (8.7%) in-hospital deaths and 28 (27%) late deaths. Overall survival at 5, 7, and 10 years was 73% +/- 5%, 68% +/- 5%, and 58% +/- 6%, respectively. At 7 years, freedom from recurrent endocarditis was 89% +/- 4% and freedom from reoperation was 94% +/- 3%. Event-free survival at 7 and 10 years was 60% +/- 6% and 46% +/- 7%, respectively, and was significantly higher in patients with native endocarditis versus those with nonnative endocarditis (ie, prosthetic or previously repaired; 7 years: 63% +/- 7% vs 50% +/- 12%, P < .005). Preoperative shock, S aureus infection, and bioprosthesis insertion were independent predictors of death from all causes. The patients in the bioprosthesis group were older (57 +/- 20 years vs 44 +/- 15 years in the mechanical group and 46 +/- 12 years in the repair group, P = .003)., Conclusions: Surgical intervention for isolated active mitral valve endocarditis remains difficult, with high morbidity and mortality in the long term. Event-free survival is worse in those who have nonnative mitral valve endocarditis.

Objective: Our objective was to examine the clinical outcomes of aortic valve replacement with the Toronto SPV bioprosthesis at 12 years., Methods: The Toronto SPV was used for aortic valve replacement in 357 patients from July 1991 to December 2004. There were 244 men and 113 women with a mean age of 65 +/- 10 years. Aortic stenosis was present in 79% of patients, coronary artery disease in 38%, and left ventricular ejection fraction less than 0.40 in 12%. Patients had an annual assessment of valve function using echocardiography. The mean duration of follow-up was 7.7 +/- 3.2 years., Results: There were 2 operative and 79 late deaths, of which 13 were valve related and 25 heart related. Survival at 12 years was 64% +/- 4% and similar to that of the general population matched for age and sex. Forty-nine patients had echocardiographic evidence of bioprosthetic dysfunction. The freedom from structural valve degeneration at 12 years was 69% +/- 4% for all patients, 52% +/- 8% for patients less than 65 years of age, and 85% +/- 4% for patients 65 years of age or older (P = .002). Fifty patients had redo aortic valve replacement: 45 for structural valve degeneration and 5 for endocarditis. The freedom from redo aortic valve replacement at 12 years was 69% +/- 4%. Cusp tear with consequent aortic insufficiency was the most common cause of structural valve degeneration. At the latest follow-up contact, 226 (63%) patients were alive with the Toronto SPV valve in place, and 69% were in functional class I, 24% in class II, and 7% in class III., Conclusions: The Toronto SPV bioprosthesis has provided optimal patient survival and symptomatic improvement but suboptimal valve durability, particularly in patients less than 65 years of age. We now use of this valve mostly in older patients who have a small aortic annulus.

Background: Stentless aortic valve reoperations may become more common as these bioprostheses reach the limits of their durability. Relatively few studies have examined stentless valve reoperation, and we therefore reviewed our results for these procedures., Methods: All patients with stentless valves undergoing redo aortic valve replacement (AVR) at our institution were examined (n = 57). Ten patients had a prior Freestyle valve (Medtronic, Minneapolis, MN), and 47 patients had a Toronto stentless porcine valve (SPV; St. Jude Medical St Paul, MN)., Results: Redo AVR was performed 8.4 +/- 3.7 years (range, 0.1 to 16.5 years) after stentless valve implantation. Reoperations were elective in 27 patients (49%), and 30 (51%) underwent urgent or emergency procedures. The indication for redo AVR was structural valve dysfunction in 48 patients (84%), acute endocarditis in 7 (12%), and other in 2 (4%). Aortic insufficiency was present in 47 patients (82%). A total of 36 aortic root replacement operations (63% of patients) were required, of which 19 were secondary to severe adhesions between the stentless valve and the native aortic root. Operative mortality was 11% (n = 6) for the entire group. Mortality was higher in patients undergoing redo AVR less than 1 year after stentless valve implantation versus more than 1 year (67% versus 7%, p = 0.03). Long-term survival at 5 years postoperatively was 79% +/- 7% in all patients, and 81% of survivors were in New York Heart Association class I or II., Conclusions: Reoperation after stentless AVR is a challenging procedure that frequently requires aortic root replacement. Stentless valve reoperation is associated with an increased risk of death, particularly in patients operated on within 1 year of implantation.

Background: The Perimount Magna valve (Edwards Lifesciences, Irvine, CA) was designed to minimize the amount of obstruction to blood flow across the valve. We compared hemodynamic performance of the Perimount Magna valve with the Hancock II valve (Medtronic, Minneapolis, MN), a second-generation porcine bioprosthesis with proven long-term results., Methods: The 57 patients who received a Magna valve at our institution from 2003 to 2005 were matched 1:1 with 57 patients who received a Hancock II valve on variables known to affect hemodynamic measurements: size of implanted valve, age, sex, and body surface area. Early postoperative transthoracic echocardiography was performed in 100% of patients., Results: In addition to the matched variables, patients in both groups were similar for all measured preoperative characteristics and perioperative clinical outcomes. One week postoperatively, Magna patients had significantly lower peak (22.1 +/- 7.4 mm Hg versus 32.3 +/- 15.1 mm Hg) and mean transvalvular gradients (10.4 +/- 4.0 mm Hg versus 18.5 +/- 15.5 mm Hg, both p < 0.001). The Magna group also had a trend towards a larger effective orifice area (1.40 +/- 0.24 cm2 versus 1.29 +/- 0.34 cm2, p = 0.07), despite a similar left ventricular outflow tract diameter (2.0 +/- 0.2 cm versus 2.0 +/- 0.1 cm, p = 0.7). Patient-prosthesis mismatch, as defined by measured effective orifice area of less than 0.65 cm2/m2, was significantly less common in the Magna group (30% versus 52%, p = 0.02)., Conclusions: The Magna valve has more favorable early postoperative hemodynamics than the Hancock II valve. Further studies should be performed comparing the Magna valve to newer-generation, low-profile porcine valves.