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For in situ tissue engineering (TE) applications it is important that implant degradation proceeds in concord with neo-tissue formation to avoid graft failure. It will therefore be valuable to have an imaging contrast agent (CA) available that can report on the degrading implant. For this purpose, a biodegradable radiopaque biomaterial is presented, modularly composed of a bisurea chain-extended polycaprolactone (PCL2000-U4U) elastomer and a novel iodinated bisurea-modified CA additive (I-U4U). Supramolecular hydrogen bonding interactions between the components ensure their intimate mixing. Porous implant TE-grafts are prepared by simply electrospinning a solution containing PCL2000-U4U and I-U4U. Rats receive an aortic interposition graft, either composed of only PCL2000-U4U (control) or of PCL2000-U4U and I-U4U (test). The grafts are explanted for analysis at three time points over a 1-month period. Computed tomography imaging of the test group implants prior to explantation shows a decrease in iodide volume and density over time. Explant analysis also indicates scaffold degradation. (Immuno)histochemistry shows comparable cellular contents and a similar neo-tissue formation process for test and control group, demonstrating that the CA does not have apparent adverse effects. A supramolecular approach to create solid radiopaque biomaterials can therefore be used to noninvasively monitor the biodegradation of synthetic implants.

Inflammation is a natural phase of the wound healing response, which can be harnessed for the in situ tissue engineering of small-diameter blood vessels using instructive, bioresorbable synthetic grafts. This process is dependent on colonization of the graft by host circulating cells and subsequent matrix formation. Typically, vascular regeneration in small animals is governed by transanastomotic cell ingrowth. However, this process is very rare in humans and hence less relevant for clinical translation. Therefore, a novel rat model was developed, in which cell ingrowth from the adjacent tissue is inhibited using Gore-Tex sheathing. Using this model, our aim here was to prove that functional blood vessels can be formed in situ through the host inflammatory response, specifically by blood-borne cells. The model was validated by implanting sex-mismatched aortic segments on either anastomoses of an electrospun poly(ɛ-caprolactone) (PCL) graft, filled with fibrin gel, into the rat abdominal aorta. Fluorescent in situ hybridization analysis revealed that after 1 and 3 months in vivo, over 90% of infiltrating cells originated from the bloodstream, confirming the effective shielding of transanastomotic cell ingrowth. Using the validated model, PCL/fibrin grafts were implanted, either or not loaded with monocyte chemotactic protein-1 (MCP-1), and cell infiltration and tissue development were investigated at various key time points in the healing cascade. A phased healing response was observed, initiated by a rapid influx of inflammatory cells, mediated by the local release of MCP-1. After 3 months in vivo, the grafts consisted of a medial layer with smooth muscle cells in an oriented collagen matrix, an intimal layer with elastin fibers, and confluent endothelium. This study proves the regenerative potential of cells in the circulatory system in the setting of in situ vascular tissue engineering.

Objective: Using magnetic resonance imaging, the authors studied the influence of a single high dose of intraoperative dexamethasone on the severity of cerebral edema that can occur early after coronary artery bypass grafting (CABG). It was hypothesized that high-dose intraoperative dexamethasone reduces cerebral edema after CABG. Design: Secondary analysis in a subset of participants of the Dexamethasone for Cardiac Surgery (DECS) trial. The DECS trial was a multicenter, randomized, double-blind, placebo-controlled trial in 4,494 cardiac surgery patients, which studied the effect of high-dose dexamethasone on mortality and major complications after cardiac surgery. Setting: A large university hospital in The Netherlands. Participants: Twenty adult patients who underwent CABG with cardiopulmonary bypass (CPB) between March and November 2011. Interventions: Participants received a single intravenous dose of dexamethasone, 1 mg/kg, or placebo, at induction of anesthesia. Measurements and Main Results: Patients underwent magnetic resonance imaging scanning immediately after surgery. The primary outcome was the severity of cerebral edema. Data from 18 patients (9 in each group, median age 69 years in both groups) could be analyzed. Patients in the dexamethasone group were (median, interquartile range 66 (53-99) minutes on cardiopulmonary bypass v 95 (81-105) minutes in the placebo group (p = 0.11). Only 1 patient in the dexamethasone group had slight cerebral edema (0% v11%, p = 1.00), and edema severity did not differ between groups (p = 1.00). Conclusions: Relevant degrees of early postoperative cerebral edema were not observed. The present study findings strongly contrasted with older studies showing cerebral edema early after CABG in most patients. (C) 2015 Elsevier Inc. All rights reserved.

Background: Postoperative atrial fibrillation (AF) is a common complication after cardiac surgery. Inflammation is believed to play a pivotal role in the etiology of postoperative AF. There is a suggestion from small studies that perioperative treatment with corticosteroids may reduce postoperative AF. The DExamethasone for Cardiac Surgery (DECS) study was a large randomized trial showing no protective effect of dexamethasone on major adverse events. The aim of this study was to investigate the effect of dexamethasone treatment on the occurrence of AF after cardiac surgery. Methods: The DECS study compared intra-operative dexamethasone (1 mg/kg) or placebo treatment in 4494 adult patients undergoing cardiac surgery. AF was defined by the occurrence of any reported AF within 30 days after surgery. We also performed an in-depth analysis of a subset of 1565 patients on new-onset AF. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated. Results: The incidence of any AF in the main study of 4494 patients was 33.1% in the dexamethasone and 35.2% in the placebo group (RR 0.94, 95% CI: 0.87-1.02, p = 0.14). In the substudy of 1565 patients, the incidence of new-onset AF was 33.0% vs. 35.5% (RR 0.93, 95% CI: 0.81-1.07, p = 0.31), respectively. There was no protective effect of dexamethasone across clinically important patient subgroups. Conclusion: Intraoperative administration of dexamethasone had no protective effect on the occurrence of any or new-onset atrial fibrillation after cardiac surgery. Therefore, the use of dexamethasone for the reduction of postoperative AF should not be recommended. (C) 2015 Elsevier Ireland Ltd. All rights reserved

In the largest single-center experience of surgical treatment for hypertrophic obstructive cardiomyopathy (HOCM), Hong et al. [(1)][1] describe the results of 174 HOCM patients in whom myectomy was combined with mitral valve surgery (MVS). In the same period, an additional 1,819 HOCM patients

Objective This pilot study evaluates the anastomotic healing of the Excimer Laser Assisted Nonocclusive Anastomosis coronary connector at 6 months in a porcine off-pump coronary artery bypass (OPCAB) model. Methods Left internal thoracic artery to left anterior descending coronary artery bypass in two animals and left internal thoracic artery to left anterior descending coronary artery and right internal thoracic artery to right coronary artery bypasses in one animal were evaluated intraoperatively and at 6 months. The anastomoses (n = 4) were examined by angiography, intravascular ultrasound, optical coherence tomography, scanning electron microscopy, and histology. Results At follow-up, all anastomoses (n = 4) were fully patent (FitzGibbon grade A). Scanning electron microscopy demonstrated complete endothelial coverage of the anastomotic surface, and histology showed minimal streamlining intimal hyperplasia. The in vivo intravascular ultrasound and optical coherence tomography acquisitions confirmed histologic findings. Optical coherence tomography demonstrated 0.06-mm intimal coverage of the intraluminal part of the connector along the full circumference of the anastomosis. Conclusions In this pilot study, the Excimer Laser Assisted Non-occlusive Anastomosis coronary connector showed an excellent healing response on the long-term in the porcine OPCAB model. Hence, this new concept might be a potential alternative to hand-sutured anastomosis in (minimally invasive) OPCAB surgery.

Echocardiography may miss prosthetic heart valve (PHV) endocarditis which advocates for novel imaging techniques to improve diagnostic accuracy and patient outcome. The purpose of this study was to determine the complementary diagnostic value of cardiac computed tomography angiography (CTA) to the clinical routine workup including transthoracic and transesophageal echocardiography (TTE/TEE) in patients with suspected PHV endocarditis and its impact on patient treatment. A diagnostic prospective cross-sectional study was chosen as design. Besides clinical routine workup (including TTE/TEE), CTA was performed to assess its diagnostic accuracy and complementary diagnostic/therapeutic value. For the diagnostic accuracy, the reference standard was surgical findings or clinical follow-up. To determine the complementary diagnostic/therapeutic value an expert-panel was used as reference standard. Twenty-eight patients were included. CTA resulted in a major diagnostic change in six patients (21 %) mainly driven by novel detection of mycotic aneurysms by CTA. Furthermore, treatment changes occurred in seven patients (25 %) compared to clinical routine workup. Diagnostic accuracy of routine clinical workup plus CTA was superior to clinical routine workup alone for the detection of PHV endocarditis in general, vegetations and peri-annular extension. This study demonstrates that CTA and clinical workup including TTE and TEE are complementary in patients with PHV endocarditis. Therefore, CTA imaging has to be considered after clinical routine workup in patients with a high suspicion on PHV endocarditis.

IN PROSTHETIC HEART VALVE (PHV) ENDOCARDITIS, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) may occasionally fail to recognize vegetations and periannular extensions (abscesses/mycotic aneurysms) due to acoustic shadowing by the metal PHV ring [(1)][1]. In

Stored red blood cells undergo progressive structural and functional changes over time. Recently, concerns have been raised about the transfusion of older red blood cell (RBC) concentrates after cardiac surgery. The objective of the study was to test the hypothesis that longer storage time of RBCs increases the risk of adverse outcome after cardiac surgery. This is a retrospective cohort study which includes patients who underwent coronary artery bypass surgery and/or valve surgery. All patients were operated in the period from September 2006 to December 2010 and received 1 to 6 units of RBCs intraoperative or after surgery. Patients were divided into two groups according to the storage time of the RBCs. The “younger” group comprised patients who received RBCs ≤14 days old (n = 111) and the “any older” group comprised patients who received RBCs >14 days old (n = 710). Using univariable and multivariable regression analysis, we examined the effect of storage time on the primary composite endpoint of death, myocardial infarction, and stroke (major adverse cardiovascular events). Secondary outcomes were prolonged ICU and hospital stay. Data of 821 patients who received a total of 2,004 RBCs were analyzed. The median storage time for the younger group was 13 ± 2 days, the median storage time for the “any older” group was 21 ± 5 days. The incidence of the primary outcome was 8.6 % in the “any older” group and 4.5 % in the younger group (adjusted odds ratio (OR) 1.68; 95 % confidence interval (CI), 0.65–4.34). Prolonged ICU stay was 12.3 % in the “any older” group and 6.3 % in the younger group (adjusted OR 1.58; 95 % CI, 0.69–3.66). In patients undergoing cardiac surgery, transfusion of RBCs stored for more than 2 weeks was not associated with adverse outcomes.

Objective The Excimer laser-assisted nonocclusive anastomotic technique is a nonocclusive, facilitated bypass technique that is currently Conformite Europeenne and Food and Drug Administration approved for clinical application in neurosurgery. In the present study, we assessed the safety and feasibility of a newly developed Excimer laser-assisted nonocclusive anastomosis-based prototype coronary anastomotic connector in an acute rabbit abdominal aortic bypass model before application in experimental coronary bypass surgery. In addition, 2 sealants were tested to facilitate anastomotic hemostasis in the current device prototype. Methods A total of 40 anastomoses were constructed on the abdominal aorta (3.5 mm outer diameter) of 10 rabbits. The anastomotic circumference was sealed by a surgical sealant to obtain complete hemostasis (BioGlue vs TachoSil). The anastomoses were evaluated by flow measurements construction time, hemostasis, histologic analysis, and burst pressure testing. Results The connector enabled a nonocclusive and fast (6.0 ± 1.7 minutes, mean ± SD [including sealing]) anastomosis construction and complete hemostasis in 95% (35/37). Sealing with BioGlue was faster than with TachoSil (19% vs 53% of construction time). Despite technical imperfections (7/40 failures to completely retrieve the flap by the laser), all 40 anastomoses were patent, showed reproducible construction with intima–adventitia apposition, streamlining thrombus coverage of the intraluminal laser rim, and no vessel wall damage. All anastomoses resisted ex vivo supraphysiologic pressures (> 300 mm Hg). Conclusions The results of the present study have demonstrated that the Excimer laser-assisted nonocclusive anastomotic connector is safe and reliable and can be efficiently applied in an acute rabbit abdominal aortic bypass model. Provided the limitations can be addressed, this easy-to-use and nonocclusive technique has the potential to facilitate minimally invasive coronary bypass surgery.

Objective Moderate to severe aortic regurgitation is occurring in 20% to 30% of cases after transcatheter aortic valve implantation. Methods The purpose of the study was to investigate the impact of a prospective policy of “oversizing” the Edwards SAPIEN bioprosthesis (Edwards Lifesciences LLC, Irvine, Calif) relative to the diameter of the aortic annulus on the rate and severity of aortic regurgitation in 28 consecutive patients initially considered eligible for transcatheter aortic valve implantation on the basis of angiography, multislice computed tomography, and transthoracic echocardiography. This policy included the systematic use of transesophageal echocardiography to exclude borderline patients and the modification of the procedure to use the larger device possible. The results were studied on an individual patient basis. Results Because 6 of 28 patients (21%) had an annulus diameter greater than 24 mm by transesophageal echocardiography, 22 patients underwent implantation of the Edwards SAPIEN prosthesis. In 6 of 22 patients, the procedure was adapted to follow our “oversizing” policy. As a result, the “prosthesis/annulus cover index” was 12.4% ± 4.3%. The procedure was successful in 21 of 22 patients (95%), and 18 patients were available for echocardiography at 1 month. Although a moderate to severe aortic regurgitation was observed pretreatment in 4 of 18 patients (22%), it was no longer the case at 1 month (0/18, 0%; P = .03). The improvement was secondary to a disappearance of the aortic regurgitation in all 7 patients with a significant aortic regurgitation at pretreatment, whereas the new aortic regurgitations appearing in 5 of the 11 patients with no aortic regurgitation at pretreatment were only mild aortic regurgitations. Conclusions In patients with a successful implantation of an Edwards SAPIEN valve, a simple “oversizing” policy based on a systematic use of transesophageal echocardiography and modification of the procedure may prevent the occurrence of moderate and severe aortic regurgitations.

Item does not contain fulltext OBJECTIVE: The study aim was to investigate the long-term prognosis and risk factors of postpericardiotomy syndrome (PPS). METHODS: We performed a single-center cohort study in 822 patients undergoing nonemergent valve surgery. Risk factors of PPS were evaluated using multivariable logistic regression analysis. We also compared the incidence of reoperation for tamponade at 1 year between patients with and without PPS. Main secondary outcomes were hospital stay and mortality. RESULTS: Of the 822 patients, 119 (14.5%) developed PPS. A higher body mass index (odds ratio (OR) per point increase, 0.94; 95% confidence interval (CI), 0.89-0.99) was associated with a lower risk of PPS, whereas preoperative treatment for pulmonary disease without corticosteroids (OR, 2.55; 95% CI, 1.25-5.20) was associated with a higher risk of PPS. The incidence of reoperation for tamponade at 1 year in PPS versus no PPS was 20.9% versus 2.5% (OR, 15.49; 95% CI, 7.14-33.58). One-year mortality in PPS versus no PPS was 4.2% versus 5.5% (OR, 0.68; 95% CI, 0.22-2.08). Median hospital stay was 13 days (interquartile range, 9-18 days) versus 11 days (interquartile range, 8-15 days) (P = .001), respectively. CONCLUSIONS: Despite longer hospital stays and more short-term reoperations for tamponade, patients with PPS had an excellent 1-year prognosis.

OBJECTIVES: Recent studies have proposed additional multidetector-row CT (MDCT) for prosthetic heart valve (PHV) dysfunction. References to discriminate physiological from pathological conditions early after implantation are lacking. We present baseline MDCT findings of PHVs 6 weeks post implantation. METHODS: Patients were prospectively enrolled and TTE was performed according to clinical guidelines. 256-MDCT images were systematically assessed for leaflet excursions, image quality, valve-related artefacts, and pathological and additional findings. RESULTS: Forty-six patients were included comprising 33 mechanical and 16 biological PHVs. Overall, MDCT image quality was good and relevant regions remained reliably assessable despite mild-moderate PHV-artefacts. MDCT detected three unexpected valve-related pathology cases: (1) prominent subprosthetic tissue, (2) pseudoaneurysm and (3) extensive pseudoaneurysms and valve dehiscence. The latter patient required valve surgery to be redone. TTE only showed trace periprosthetic regurgitation, and no abnormalities in the other cases. Additional findings were: tilted aortic PHV position (n = 3), pericardial haematoma (n = 3) and pericardial effusion (n = 3). Periaortic induration was present in 33/40 (83 %) aortic valve patients. CONCLUSIONS: MDCT allowed evaluation of relevant PHV regions in all valves, revealed baseline postsurgical findings and, despite normal TTE findings, detected three cases of unexpected, clinically relevant pathology. KEY POINTS: • Postoperative MDCT presents baseline morphology relevant for prosthetic valve follow-up. • 83 % of patients show periaortic induration 6 weeks after aortic valve replacement. • MDCT detected three cases of clinically relevant pathology not found with TTE. • Valve dehiscence detection by MDCT required redo valve surgery in one patient. • MDCT is a suitable and complementary imaging tool for follow-up purposes.

Transcatheter aortic valve implantation (TAVI) is a novel, less-invasive technique used to treat selected patients with severe aortic valve stenosis with a high surgical risk. Noninvasive imaging before, during and after the procedure is of the utmost importance in this minimally invasive procedure. Screening of the patient and sizing of the aortic root by echocardiography and multislice computed tomography is of great importance to ensure success of the TAVI procedure. Echocardiography and fluoroscopy are essential during the procedure. During follow-up of the patients, echocardiography is important to evaluate the prosthesis function, durability and integrity. Additionally, multislice computed tomography and MRI might be helpful in the follow-up of selected cases. This article outlines the evolving role of multimodality imaging throughout TAVI in patients with severe aortic valve stenosis. It describes, in a stepwise approach, how multimodality imaging by echocardiography, angiography, multislice computed tomography and MRI enhances the TAVI procedure.

For clinical application of tissue engineering strategies, the use of animal-derived serum in culture medium is not recommended, because it can evoke immune responses in patients. We previously observed that human platelet-lysate (PL) is favourable for cell expansion, but generates weaker tissue as compared to culture in foetal bovine serum (FBS). We investigated if human serum (HS) is a better human supplement to increase tissue strength. Cells were isolated from venous grafts of 10 patients and expanded in media supplemented with PL or HS, to determine proliferation rates and expression of genes related to collagen production and maturation. Zymography was used to assess protease expression. Collagen contraction assays were used as a two-dimensional (2D) model for matrix contraction. As a prove of principle, 3D tissue culture and tensile testing was performed for two patients, to determine tissue strength. Cell proliferation was lower in HS-supplemented medium than in PL medium. The HS cells produced less active matrix metallo-proteinase 2 (MMP2) and showed increased matrix contraction as indicated by gel contraction assays and 3D-tissue culture. Tensile testing showed increased strength for tissues cultured in HS when compared to PL. This effect was more pronounced if cells were sequentially cultured in PL, followed by tissue culture in HS. These data suggest that sequential use of PL and HS as substitutes for FBS in culture medium for cardiovascular tissue engineering results in improved cell proliferation and tissue mechanical properties, as compared to use of PL or HS apart.

OBJECTIVES: To describe the early and late outcomes of carcinoid patients undergoing surgical heart valve replacement. METHODS: In a retrospective study, records of patients with symptomatic carcinoid heart disease referred for valve surgery between 1993 and 2010 at two academic centres were reviewed. The perioperative and postoperative outcomes were analysed. RESULTS: Nineteen patients, with a mean age of 56 ± 9.6 years, underwent cardiac surgery for carcinoid syndrome. Sixteen patients underwent implantation of one or more mechanical bileaflet valve prosthesis and three patients had one or more bioprosthetic valves implanted. Survival after 1 and 5 years was 71 and 43%, respectively. Six out of nine survivors were at last follow-up in New York Heart Association class I. Valve-related events such as valve thrombosis or bleeding complications were not registered. Echocardiography showed improvement of right ventricular dilatation in 80% of patients. CONCLUSIONS: Despite advanced cardiac morbidity at the time of operation, early postoperative survival was 90%. Long-term survival of patients with carcinoid heart disease undergoing valve replacement is determined by carcinoid progression. The surviving patients had a persistent improvement in functional capacity without valve-related complications of the mechanical prosthesis.

Cardiac pulsatility and aortic compliance may result in aortic area and diameter changes throughout the cardiac cycle in the entire aorta. Until this moment these dynamic changes could never be established in the aortic root (aortic annulus, sinuses of Valsalva and sinotubular junction). The aim of this study was to visualize and characterize the changes in aortic root dimensions during systole and diastole with ECG-gated multidetector row computed tomography (MDCT). MDCT scans of subjects without aortic root disease were analyzed. Retrospectively, ECG-gated reconstructions at each 10% of the cardiac cycle were made and analyzed during systole (30–40%) and diastole (70–75%). Axial planes were reconstructed at three different levels of the aortic root. At each level the maximal and its perpendicular luminal dimension were measured. The mean dimensions of the total study group (n = 108, mean age 56 ± 13 years) do not show any significant difference between systole and diastole. The individual dimensions vary up to 5 mm. However, the differences range between minus 5 mm (diastolic dimension is greater than systolic dimensions) and 5 mm (vice versa). This variability is independent of gender, age, height and weight. This study demonstrated a significant individual dynamic change in the dimensions of the aortic root. These results are highly unpredictable. Most of the healthy subjects have larger systolic dimensions, however, some do have larger diastolic dimensions.

Prosthetic heart valve (PHV) dysfunction is a rare, but potentially life-threatening, complication. In clinical practice, PHV dysfunction poses a diagnostic dilemma. Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice. However, these techniques sometimes fail to determine the specific cause of PHV dysfunction, which is crucial to the selection of the appropriate treatment strategy. Multidetector-row CT (MDCT) can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complimentary information for surgical planning in case of reoperation. Cardiac magnetic resonance imaging (CMR) has limited value in the evaluation of biological PHV dysfunction. In this Review, we discuss the use of established imaging modalities for the detection of left-sided mechanical and biological PHV dysfunction and discuss the complementary role of MDCT in this context.

Ongoing research efforts aim at improving the creation of tissue-engineered heart valves for in vivo systemic application. Hence, in vitro studies concentrate on optimising culture protocols incorporating biological as well as biophysical stimuli for tissue development. Important lessons can be drawn from valvulogenesis to mimic natural valve development in vitro. Here, we review the up-to-date status of valvulogenesis, focussing on the biomolecular and biophysical regulation of semilunar valve development. In addition, we discuss potential benefits of incorporating concepts derived from valvulogenesis, as well as alternative approaches, in tissue-engineering protocols, to improve in vitro valve development. The combined efforts from clinicians, cell biologists and engineers are required to implement and evaluate these approaches to achieve optimised protocols for heart-valve tissue engineering.

Objective Endoventricular circular patch plasty is a method used to reconstruct the ventricular cavity in patients with (post) ischemic left ventricular aneurysm or global dilatation. However, late redilatation with mitral regurgitation has been reported, in which postoperative apex shape seems to play an important role. We studied the feasibility of ventricular volume downsizing with a variably shaped patch in porcine hearts. Methods In five in vitro and two acute animal experiments, a dyskinetic aneurysm was simulated with a pericardial insert. Reducing patch surface by changing patch shape diminished end-diastolic volume. In vitro, static end-diastolic volume was determined for each patch shape using volumetry and echocardiography. In the acute animal experiments, preliminary observations of patch behavior in live material were made, and pressure/time relationship, dPdTmax, was registered. Results In vitro, bringing the convex patch into a flat plane reduced LV volume from 66 ± 7 mL (aneurysm) to 49 ± 5 mL. Four of 5 patch shapes further reduced volume to a mean of 38 ± 7 mL (P = 0.03). The in vitro echocardiographic measurements correlated with volumetry findings (r = 0.81). In the acute animal experiments, dPdTmax varied with patch shape, independent of volume changes. Conclusions In this pilot study, in vitro shape configuration of the resizable ventricular patch resulted in a calibrated end-diastolic volume reduction. The data of the two in vivo pilot experiments clearly indicate that change in patch configuration in the situation of more or less unchanged end-diastolic volume had impact on cardiac performance. Future studies must substantiate the results of this observation.

Background: Health related quality-of-life (HRQL) beyond one year of treatment of multivessel coronary artery disease with stenting or coronary artery bypass grafting (CABG) is yet unknown. The Arterial Revascularisation Therapy Study (ARTS) was designed to compare CABG and stenting in multivessel disease. Methods and results: HRQL was evaluated at baseline, at 1- month and at 6-, 12- and 36 months after revascularisation using the Short Form Health Survey (SF-36) in patients randomised to stenting (n=483) versus CABG (n=492). Both stenting and CABG resulted in significant improvement of HRQL and anginal status. Although there was a trend for better HRQL after CABG up to one year, the disparity between the two procedures decreased long-term. Most of the difference between the two procedures was attributed to repeat interventions in the stent group; at three years, 19% of stent patients versus 13% of CABG patients (p

Severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HC) may benefit from surgical myectomy. In patients with enlarged mitral leaflets and mitral regurgitation, myectomy can be combined with anterior mitral leaflet extension (AMLE) to stiffen the midsegment of the leaflet. The aim of this study was to evaluate the long-term results of myectomy combined with AMLE in patients with obstructive HC. This prospective, observational, single-center cohort study included 98 patients (49 +/- 14 years, 37% female) who underwent myectomy combined with AMLE from 1991 to 2012. End points included all-cause mortality and change in clinical and echocardiographic characteristics. Mortality was compared with age- and gender-matched patients with nonobstructive HC and subjects from the general population. Long-term follow-up was 8.3 +/- 6.1 years. There was no operative mortality, and New York Heart Association class was reduced from 2.8 +/- 0.5 to 1.3 +/- 0.5 (p

The implanted prosthetic heart valve (PHV) size is vital for the evaluation of suspected PHV dysfunction and in case of reoperation or valve-in-Valve transcatheter approaches. The labeled size is not always known, and discrepancies exist between manufacturers' labeled sizes and true sizes. Reproducible methods for noninvasive PHV size assessment are lacking. We determined the reliability and agreement of PHV size measurements using multidetector-row computed tomography (MDCT) and provide reference values of MDCT measurements compared with manufacturer specifications. In vitro, 15 different PHV types in available sizes (total n = 63) were imaged. In vivo, available MDCT acquisitions of patients with PHVs were retrospectively gathered in 2 centers, and 230 patients with 249 PHVs were included. Inner valve area and area-derived diameter were measured in all PHVs. For mechanical PHVs, the inner diameter was also measured. Data were analyzed using the intraclass correlation coefficient and Bland-Altman plots and related to manufacturer specifications. Measurements could be obtained for all PHV types, except the Bjork-Shiley (n = 7) because of severe valve-related artifacts hampering the image quality. Intrarater and interrater reliability was excellent for biological and mechanical PHVs (intraclass correlation coefficients (>= 1.903). Agreement was good for all measurements with an overall maximal mean difference (95% confidence interval) of -2.61 mm(2) (-37.9 to 32.7), -0.1 mm (-1.1 to 1.0), and 0 mm (-0.4 to 0.3) for valve area, area-derived diameter, and inner diameter, respectively. MDCT reliably discriminated consecutive PHV sizes as labeled by the manufacturer because the absolute ranges for the measurements never overlapped. In conclusion, MDCT allows assessment of the implanted PHV size with excellent reliability and agreement and can discriminate between PHV sizes for contemporary prostheses. MDCT can be used to non-invasively identify the manufacturer-labeled PHV size. (C) 2015 Elsevier Inc. All rights reserved.

Objectives: Retrospective ECG-gated multidetector-row computed tomography (MDCT) is increasingly used for the assessment of prosthetic heart valve (PHV) dysfunction, but is also hampered by PHV-related artefacts/cardiac arrhythmias. Furthermore, it is performed without nitroglycerine or heart rate correction. The purpose was to determine whether MDCT performed before potential redo-PHV surgery is feasible for concomitant coronary artery stenosis assessment and can replace invasive coronary angiography (CAG). Methods: PHV patients with CAG and MDCT were identified. Based on medical history, two groups were created: (I) patients with no known coronary artery disease (CAD), (II) patients with known CAD. All images were scored for the presence of significant (>50 %) stenosis. CAG was the reference test. Results: Fifty-one patients were included. In group I (n = 38), MDCT accurately ruled out significant stenosis in 19/38 (50 %) patients, but could not replace CAG in the remaining 19/38 (50 %) patients due to non-diagnostic image quality (n = 16) or significant stenosis (n = 3) detection. In group II (n = 13), MDCT correctly found no patients without significant stenosis, requiring CAG imaging in all. MDCT assessed patency in 16/19 (84 %) grafts and detected a hostile anatomy in two. Conclusion: MDCT performed for PHV dysfunction assessment can replace CAG (100 % accurate) in approximately half of patients without previously known CAD. Key Points: • Retrospective MDCT is increasingly used for prosthetic heart valve dysfunction assessment • In case of PHV reoperation, invasive coronary angiography is also required • MDCT can replace CAG in 50 % of patients without coronary artery disease • When conclusive for coronary assessment, MDCT stenosis rule out is highly accurate • Replacing CAG saves associated risks of distant embolization of thrombi or vegetations

Objective: This study aimed at calculating and comparing the long-term outcomes of patients after aortic valve replacement with the Carpentier-Edwards bovine pericardial and porcine supraannular bioprostheses using microsimulation. Methods: We conducted a meta-analysis of eight studies on the Carpentier-Edwards pericardial valves (2685 patients, 12,250 patient-years) and five studies on the supraannular valves (3796 patients, 20,127 patient-years) to estimate the occurrence rates of valve-related events. Eighteen-year follow-up data sets were used to construct age-dependent Weibull curves that described their structural valvular deterioration. The estimates were entered into a microsimulation model, which was used to calculate the outcomes of patients after aortic valve replacement. Results: The annual hazard rates for thromboembolism after aortic valve replacement were 1.35% and 1.76% for the pericardial and supraannular valves, respectively. For a 65-year-old male, median time to structural valvular deterioration was 20.1 and 22.2 years while the lifetime risk of reoperation due to structural valvular deterioration was 18.3% and 14.0%, respectively. The life expectancy of the patient was 10.8 and 10.9 years and event-free life expectancy 9.0 and 8.8 years, respectively. Conclusions: The microsimulation methodology provides insight into the prognosis of a patient after aortic valve replacement with any given valve type. Both the Carpentier-Edwards pericardial and supraannular valve types perform satisfactorily, especially in elderly patients, and show no appreciable difference in long-term outcomes when implanted in the aortic position. # 2005 Elsevier B.V. All rights reserved.

Objectives The long-term (five-year) comparative results of treatment of multivessel coronary artery disease with stenting or coronary artery bypass grafting (CABG) is at present unknown. Background The Arterial Revascularization Therapies Study (ARTS) was designed to compare CABG and stenting in patients with multivessel disease. Methods A total of 1,205 patients with the potential for equivalent revascularization were randomly assigned to CABG (n = 605) or stent implantation (n = 600). The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events (MACCE) at one year; MACCE at five-year follow-up constituted the final secondary end point. Results At five years, there were 48 and 46 deaths in the stent and CABG groups, respectively (8.0% vs. 7.6%; p = 0.83; relative risk [RR], 1.05; 95% confidence interval [CI], 0.71 to 1.55). Among 208 diabetic patients, mortality was 13.4% in the stent group and 8.3% in the CABG group (p = 0.27; RR, 1.61; 95% CI, 0.71 to 3.63). Overall freedom from death, stroke, or myocardial infarction was not significantly different between groups (18.2% in the stent group vs. 14.9% in the surgical group; p = 0.14; RR, 1.22; 95% CI, 0.95 to 1.58). The incidence of repeat revascularization was significantly higher in the stent group (30.3%) than in the CABG group (8.8%; p Conclusions At five years there was no difference in mortality between stenting and surgery for multivessel disease. Furthermore, the incidence of stroke or myocardial infarction was not significantly different between the two groups. However, overall MACCE was higher in the stent group, driven by the increased need for repeat revascularization.

Background The second-generation Carpentier-Edwards pericardial valve (Edwards Lifesciences LLC, Irvine, CA) is widely used for aortic valve replacement. However, knowledge on the long-term outcomes of patients after valve implantation is incomplete. We used microsimulation to calculate the long-term outcome of any given patient after aortic valve replacement with the Carpentier-Edwards pericardial valve. Methods A meta-analysis of 8 reports on aortic valve replacement with the Carpentier-Edwards pericardial valve (2,685 patients; 12,250 patient years) was used to estimate the hazards of valve-related events other than structural valvular deterioration. Structural valvular deterioration was described by age-dependent Weibull curves calculated from 18-year follow-up, premarket approval, Carpentier-Edwards pericardial primary data. These estimates provided the input data for the parameters of the microsimulation model, which was then used to calculate the outcomes of patients of different ages after valve implantation. The model estimates of survival were validated using two external data sets. Results The Weibull analysis estimated a median time to reoperation for structural valvular deterioration ranging from 18.1 years for a 55-year-old male to 23.2 years for a 75-year-old male. For a 65-year-old male, microsimulation calculated a life expectancy and event-free life expectancy of 10.8 and 9.1 years, respectively. The lifetime risk of at least one valve-related event was 38% and that of reoperation due to structural valvular deterioration 17%, respectively, for this patient. The model estimates of survival showed good agreement with external data. Conclusions Microsimulation provides detailed insight into the long-term prognosis of patients after aortic valve replacement. The Carpentier-Edwards pericardial valve performs satisfactorily and offers a low lifetime risk of reoperation due to structural valvular deterioration, especially for elderly patients requiring aortic valve replacement.

Aims Sirolimus-eluting stents (SES) have recently been shown to reduce restenosis in selected patients. The impact of this new stent on the use of coronary bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in clinical practice is yet unknown. Therefore, we investigated the impact of SES on the clinical practice of CABG and PCI in a series of unselected consecutive patients. Methods and results Between April and October 2002, a policy of SES implantation for all procedures has been instituted in our hospital. In total, 798 patients were referred to PCI and 275 to CABG (SES group). A control group was composed of all interventions (806 PCI and 314 CABG) performed during the preceding 6 months (pre-SES). The main outcome was the occurrence of major adverse cardiac events (MACE) at 15 months. In the SES era, a significant shift was noted in the PCI group towards more multi-vessel stenting (28 vs. 24%; P

Since the mid-1980s, (intra-operative) two-dimensional echocardiography has considerably increased our knowledge and understanding of the pathology of hypertrophic obstructive cardiomyopathy (HOCM) and the intracardiac effects of our surgical interventions. The variability in the distribution of left ventricular hypertrophy, the usually increased antero-posterior diameter of the anterior mitral leaflet and other pathology such as the abnormal insertion of papillary muscles in the anterior mitral leaflet were recognized with echocardiography and visual inspection as specific conditions in these patients. 1-3 Intraoperative and postoperative echocardiography provided also insight in the limitations of the classic Morrow operation, such as residual outflow gradients immediately after extracorporeal circulation and residual mitral regurgitation. 4,5 This instantaneous echocardiographic feed back made surgeons aware of possible improvements of the surgical procedure, such as immediate re-intervention on the basis of intra-operative echocardiographic data, a more rigorous and extensive myectomy and manipulation of the anterior mitral leaflet. The rise (and fall) of the pacemaker therapy for HOCM and other noninvasive treatment options was the incentive for many surgical centers to review their results with septal myo-myectomy. In general, 90% to 95% of the patients had a substantial reduction of the left ventricular outflow tract gradient and this was in 70% to 95% of the patients associated with a substantial and lasting improvement of symptoms. 6,7 Despite these good results, the findings suggested room for improvement from the perspective of residual gradients and symptoms. Intra-operative echocardiography has been used to assess the outcome of myectomy, but the results of immediate reintervention have been disappointing. In contrast to mitral reconstruction, a second pump run was in one series associated with unusual morbidity and mortality. 8 In general, op

Background Aortic root replacement with cryopreserved allografts is associated with excellent hemodynamics, little endocarditis, low thromboembolic event rates, and no need for anticoagulation. There is, however, concern regarding the long-term durability of this valve substitute, especially in younger patients. Meta-analysis and microsimulation were used to calculate age-specific long-term prognosis after allograft aortic root replacement based on current evidence. Methods Our center's experience with cryopreserved allograft aortic root replacement in 165 adult patients was combined in a meta-analysis with reported and individual results from four other hospitals. Using this information, the microsimulation model predicted age- and gender-specific total and reoperation-free and event-free life expectancy. Results The pooled results comprised 629 patients with a total follow-up of 1860 patient-years (range 0 to 12.8 years). Annual risks were 0.6% for thromboembolism, 0.05% for bleeding, 0.5% for endocarditis, and 0.5% for nonstructural valve failure. Structural allograft failure requiring reoperation occurred in 15 patients, and a patient age–specific Weibull function was constructed accordingly. Calculated total life expectancy varied from 27 years in a 25-year-old to 12 years in a 65-year-old male; corresponding actual lifetime risk of reoperation was 89% and 35%, respectively. Conclusions Cryopreserved aortic allografts have an age-related limited durability. This results in a considerable lifetime risk of reoperation, especially in young patients. The combination of meta-analysis and microsimulation provides an appropriate tool for estimating individualized long-term outcome after aortic valve replacement and can be useful both for patient counseling and prognostic research purposes.

FIGURE 1. Echocardiographic images. A, Preoperative transesophageal echo anterior mitral valve leaflet in late systole. B, Preoperative transthoracic echoca operative epicardial echocardiographic 4-chamber view demonstrating patch of diogram of left ventricular outflow tract indicating neither systolic anterior mo From the Division of Heart and Lungs, Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; the Department of Cardiology, Medisch Centrum Haaglanden, The Hague, The Netherlands; and the Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Sept 16, 2011; revisions received Oct 25, 2011; accepted for publication Nov 8, 2011; available ahead of print Jan 13, 2012. Address for reprints: Jesper Hjortnaes, MD, Department of Cardiothoracic Surgery, Division Heart and Lungs, University Medical Center Utrecht, Heidelberglaan 100, E03.511, PO Box 85500, 3508GA Utrecht, The Netherlands (E-mail: j.hjortnaes@umcutrecht.nl). J Thorac Cardiovasc Surg 2012;144:506-8 0022-5223/$36.00 Copyright 2012 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2011.11.020

To simplify and facilitate beating heart (i.e., off-pump), minimally invasive coronary artery bypass surgery, a new coronary anastomotic connector, the Trinity Clip, is developed based on the excimer laser-assisted nonocclusive anastomosis technique. The Trinity Clip connector enables simplified, sutureless, and nonocclusive connection of the graft to the coronary artery, and an excimer laser catheter laser-punches the opening of the anastomosis. Consequently, owing to the complete nonocclusive anastomosis construction, coronary conditioning (i.e., occluding or shunting) is not necessary, in contrast to the conventional anastomotic technique, hence simplifying the off-pump bypass procedure. Prior to clinical application in coronary artery bypass grafting, the safety and quality of this novel connector will be evaluated in a long-term experimental porcine off-pump coronary artery bypass (OPCAB) study. In this paper, we describe how to evaluate the coronary anastomosis in the porcine OPCAB model using various techniques to assess its quality. Representative results are summarized and visually demonstrated.

OBJECTIVES: The aim was to describe procedural volumes, patient risk profile and outcomes of heart valve surgery in the past 16 years in Netherlands. METHODS: The Dutch National Database for Cardio-Thoracic Surgery includes approximately 200 000 cardiac operations performed between 1995 and 2010. Information on all valve surgeries (56 397 operations) was extracted. We determined trends for changes in procedural volume, demographics, risk profile and in-hospital mortality of valve operations. Because of incomplete data in the first years of registration, the total number of operations in those years was estimated using Poisson regression. For a subset from 2007 to 2010, follow-up data were available. Survival status was obtained through linkage with the national Cause of Death Registry, and survival analysis was performed using Kaplan–Meier method. Information on discharge and readmissions was obtained from the National Hospital Discharge Registry. RESULTS: The annual volume of heart valve operations increased by more than 100% from an estimated 2431 in 1995 to 5906 in 2010. Adjusted for population size in Netherlands, the number of operations per 100 000 adults increased from 20 in 1995 to 43 in 2010. In 2010, frequently performed valve surgery included the following: 34.6% isolated aortic valve (AoV) replacement, 21.8% AoV replacement and coronary artery bypass grafting (CABG), 14.6% isolated mitral valve surgery (repair or replacement) and 9.1% mitral valve and CABG. In AoV surgery, an increasing use of bioprostheses in all age categories is observed. In mitral valve surgery, 75.4% was performed by repair rather than replacement in 2010. In-hospital mortality for all valve surgery decreased significantly from 4.6% in 2007 to 3.6% in 2010, whereas the mean logistic EuroSCORE remained stable (median 5.8, P= 1.000). Thirty-day mortality after all valve surgery was 3.9% and 120-day mortality was 6.5%. At 1 year, survival after all valve surgery was 91.6% and a reoperation had been performed in 1.6%. The median postoperative length of stay was 7 days (interquartile range (IQR) 5–11) in the primary hospital and 11 days (IQR 8–16), including subsequent stay, in the secondary hospital. CONCLUSIONS: The results of this study provide a comprehensive overview of valve surgery trends and outcomes in Netherlands. The number of heart valve operations performed in Netherlands has increased since 1995. The significant decrease in mortality and unchanged EuroSCORE between 2007 and 2010 might reflect a general improvement of the safety of valve surgery.

Background —Human tissue valves for aortic valve replacement have a limited durability that is influenced by interrelated determinants. Hierarchical linear modeling was used to analyze the relation between these determinants of durability and valve regurgitation measured by serial echocardiography. Methods and Results —In adult patients, 218 cryopreserved aortic allografts were implanted with the subcoronary (85) or the root replacement technique (133), and 81 patients had root replacement with a pulmonary autograft. Mean follow-up was 4.2 years (SD 2.7; range, 0 to 10.5). Patient age, operator experience with subcoronary implantation, and allograft diameter were independent predictors for reoperation. With repeated color Doppler echocardiography, the severity of aortic regurgitation was assessed by the jet length method and the jet diameter ratio. Multilevel hierarchical linear modeling was used to estimate initial aortic regurgitation (intercept), its change over time (slope), and the effect of 11 potential determinants of durability on aortic regurgitation. With the jet length method, the intercept was 0.94 grade and the slope was 0.11 grade per year. With the jet diameter ratio, the intercept was 0.34 and the annual increase was 0.01. Subcoronary implanted valves had more initial aortic regurgitation, but progression of aortic valve regurgitation did not differ from root replacement. At midterm follow-up, recipient age Conclusions —Subcoronary implantation has a learning curve, resulting in more initial aortic regurgitation and early reoperation compared with root replacement. In both techniques, progression of aortic regurgitation over time is small but accelerated in young adults.

Coronary artery (CA) imaging has relied on invasive techniques for diagnosing stenotic lesions. Two-dimensional techniques are limited in obtaining optimal longitudinal views of all segments of the CA because of their spatial orientations. Three-dimensional echocardiography (3DE) may produce any desired cross-sectional views and reconstruct 3-dimensional images from a volumetric data set. Its role in CA imaging has not been fully explored. The aim of this study was to evaluate the potential of 3DE in visualizing CAs and in assessing the severity of stenosis. We performed transesophageal 3DE in 46 patients. Images were collected sequentially with the transducer rotated through 180 degrees. From the 3DE data sets of all 46 patients, cross-sectional views and 3-dimensional images of CAs were reconstructed. For segment-by-segment comparison between CA angiography and 3DE in semiquantitative analysis of coronary stenosis, 5 segments were defined for the proximal CA tree in 20 patients who underwent both procedures. The left main, anterior descending, circumflex, and right CAs were visualized from 3DE in 100%, 100%, 98%, and 72%. The available lengths of these segments from 3DE were 12+/-4 mm (range 4 to 22), 15+/-6 mm (range 6 to 36), 30+/-12 mm (range 13 to 60), and 18+/-9 mm (range 6 to 36), respectively. Comparison between 3DE and CA angiography in semiquantitative estimation of CA stenosis resulted in complete agreement in 83% of the segments (kappa value = 0.7). The sensitivity and specificity of 3DE in detecting significant stenosis (> or =50%) were 84% and 97%. In conclusion, transesophageal 3DE allows imaging of the proximal CA, detection of stenotic lesions, and estimation of the severity of stenosis.

Background. The diagnosis of allograft-specific pathology by echocardiography has important consequences for patient counseling and research. This study describes the pathomorphologic findings and color Doppler jet patterns in a consecutive series of patients after allograft placement with either the subcoronary implantation or root replacement technique. Methods. From 1987 to July 1996, the subcoronary allograft implantation technique and root replacement technique were used in 82 patients and 70 patients, respectively. These patients comprised the study group. Results. The incidence of paravalvular leaks and eccentric regurgitant jets was higher with subcoronary implantation (41%) than with root replacement (11%). Patients with a subcoronary implanted allograft had a higher incidence of eccentric jets. Conclusions. These findings support the concept of preservation of valve geometry after root replacement, as allograft-specific pathomorphologic abnormalities and eccentric jets are more common after subcoronary implantation of allografts. Learning effects, however, cannot be excluded as the cause of these abnormalities.

Objective: The objective of this study was to discern the fate of the pulmonary autograft diameter over time in adults and its relation to aortic regurgitation in the setting of aortic root replacement. Methods: From January 1989 to May 1995, 36 consecutive adult patients underwent aortic root replacement with a pulmonary autograft for aortic valve disease. The mean age of 20 male and 16 female patients was 29.1 years (range 19.3 to 52.1 years). The mean follow-up was 2.3 years (range 0.3 to 6.0 years). Two patients died in the hospital. One other patient had a second operation for stenosis at the distal suture line of the allograft in the pulmonary position. Pulmonary autograft anulus and sinus diameters were measured with epicardial echocardiography before (only anulus) and after cardiopulmonary bypass, with transthoracic echocardiography at hospital discharge, and with transesophageal echocardiography during follow-up. Results: The mean autograft anulus diameter did not increase immediately after cardiopulmonary bypass (mean diameter 26.2 mm before and 26.4 mm after cardiopulmonary bypass). The mean autograft sinus diameter after cardiopulmonary bypass was 36.5 mm. The mean autograft anulus diameter increased to 31.5 mm at follow-up, an increase of 5.1 mm (19%). The mean autograft sinus diameter increased to 43.9 mm at follow-up, an increase of 7.4 mm (20%). Fifty-nine percent of the anulus diameter increase and 40% of the sinus diameter increase was already reached at hospital discharge (7 to 10 days after the operation); the other part of the increase occurred during follow-up. Diameter increase was associated with neither the length of follow-up (follow-up less than 1 year compared with a longer follow-up) or severity of aortic regurgitation. Conclusion: Pulmonary autograft anulus and sinus diameters increase the first year after aortic root replacement with a pulmonary autograft. This occurs rapidly within 10 days after the operation, with a further increase during follow-up, without causing significant aortic regurgitation at medium-term follow-up. (J Thorac Cardiovasc Surg 1997;113:655-66)

OBJECTIVES: The aim of our study was to investigate early mortality after cardiac surgery and to determine the most adequate followup period for the evaluation of mortality rates. METHODS: Information on all adult cardiac surgery procedures in 10 of 16 cardiothoracic centres in Netherlands from 2007 until 2010 was extracted from the database of Netherlands Association for Cardio-Thoracic Surgery (n= 33 094). Survival up to 1 year after surgery was obtained from the national death registry. Survival analysis was performed using Kaplan–Meier and Cox regression analysis. Benchmarking was performed using logistic regression with mortality rates at different time points as dependent variables, the logistic EuroSCORE as covariate and a random intercept per centre. RESULTS: In-hospital mortality was 2.94% (n= 972), 30-day mortality 3.02% (n= 998), operative mortality 3.57% (n= 1181), 60-day mortality 3.84% (n= 1271), 6-month mortality 5.16% (n= 1707) and 1-year mortality 6.20% (n= 2052). The survival curves showed a steep initial decline followed by stabilization after 60–120 days, depending on the intervention performed, e.g. 60 days for isolated coronary artery bypass grafting (CABG) and 120 days for combined CABG and valve surgery. Benchmark results were affected by the choice of the follow-up period: four hospitals changed outlier status when the follow-up was increased from 30 days to 1 year. In the isolated CABG subgroup, benchmark results were unaffected: no outliers were found using either 30-day or 1-year follow-up. CONCLUSIONS: The course of early mortality after cardiac surgery differs across interventions and continues up to 120 days. Thirtyday mortality reflects only a part of early mortality after cardiac surgery and should only be used for benchmarking of isolated CABG procedures. The follow-up should be prolonged to capture early mortality of all types of interventions.

Mitral regurgitation is the second most frequent valvular heart disease. Echocardiography is the principal examination to determine severity, mechanism and hemodynamic consequences of mitral regurgitation and consequently contributes to the assessment and accurate timing of the best treatment strategy. To clarify clinical decision making in severe mitral regurgitation, this review will discuss the diagnostic work-up and treatment options according to the most recent guidelines. Mitral valve surgery, preferably repair, is indicated in symptomatic patients with severe, organic mitral regurgitation. Chronic, functional mitral regurgitation is often medically treated (including cardiac resynchronization therapy if indicated), however surgery (preferably annuloplasty) can be recommended. Percutaneous MitraClip-implantation may be considered as an alternative option in symptomatic patients with severe mitral regurgitation who are considered inoperable. At present, there is no consensus on the optimal care in asymptomatic patients with severe, organic mitral regurgitation and preserved left ventricular function. A prospective trial is highly needed to elucidate this best treatment strategy.

Perivascular adipose tissue (pvAT) may induce a local pro-inflammatory environment, possibly contributing to coronary atherosclerosis. We investigated whether there is a difference in adipocytokine production by pvAT near stenotic and non-stenotic coronary artery segments in patients with coronary artery disease (CAD).In patients undergoing CABG with or without valve replacement (n = 38) pvAT near stenotic and near non-stenotic coronary segments was harvested. PvAT was incubated ex vivo for 24h. Concentrations of 23 adipocytokines were measured in the supernatants with a Multiplex assay. The number of macrophages (CD68, CD11c, CD206) and lymphocytes (CD45) in pvAT was determined. Differences between stenosis and control pvAT were tested with Wilcoxon signed rank test corrected for multiple comparisons.Production of IL-5, IL-1α, IL-17, IL-18 and IL-23 was higher in control than stenosis pvAT samples (p0.0021). Macrophages were more abundant in stenosis than in control pvAT (median n/400× field: 2.3 IQR: 0.3-4.5 versus 1.2 IQR: 0.1-2.5). There was a predominance of M2 macrophages in both stenosis and control pvAT (median n/400× field: macrophages stenosis: M1: 0.0; M2: 1.0 p = 0.004; control: M1: 0.0; M2: 0.6 p = 0.013). The relation between adipocytokine production and macrophage infiltration was not different in stenosis and control pvAT.In patients with CAD, multiple adipocytokines were secreted at higher levels by pvAT near non-stenotic than near stenotic coronary artery segments. Furthermore, pvAT macrophages are associated with stenosis of the adjacent vessel. M2 macrophages were more abundant than M1 macrophages in pvAT.

OBJECTIVES: Guidelines recommend surgical mitral valve repair in selected patients with asymptomatic severe mitral valve regurgitation (MR), but the role of repair remains a matter of debate. Survival analyses of operated asymptomatic patients have been reported, but long-term haemodynamics and quality of life are not well defined. The aim of this study was to report the long-term follow-up focusing on these aspects. METHODS: Our database identified patients who underwent primary isolated mitral valve repair for severe MR and were asymptomatic by New York Heart Association Class I and in sinus rhythm. To obtain sufficient length of follow-up, only patients operated on before 2006 returned for an echocardiogram and quality-of-life assessment (SF-36). RESULTS: Between May 1991 and December 2005, 46 asymptomatic patients with severe MR and a normal left ventricular function (ejection fraction >60%) were operated on. Mean age was 50.2 ± 13.2 years and 89% of patients were male. There were no operative deaths. Mean follow-up was 8.4 ± 3.9 years with 386 patient-years, survival was 93.3% at 12 years and comparable with the general age-matched Dutch population. Follow-up echocardiography showed that 92% had no to mild MR, and 3 patients had moderate MR. Left ventricular function was good/impaired/moderate in 66/29/5% of patients. Quality-of-life SF-36 assessment showed that mean physical and mental health components were 83 ± 17 and 79 ± 17, which was comparable with that of the general age- and gender-matched Dutch population. CONCLUSIONS: Our experience shows that mitral valve repair for severe MR in asymptomatic patients is safe, and has satisfactory long-term survival with a low recurrence rate of MR, good left ventricular function, and excellent quality of life that is comparable with the general Dutch population.

Background— Comparison of outcomes requires adequate risk adjustment for differences in patient risk and the type of intervention performed. Both unintentional and intentional misclassification (also called gaming) of risk factors might lead to incorrect benchmark results. Therefore, misclassification of risk factors should be detected. We investigated the use of statistical process control techniques to monitor the frequency of risk factors in a clinical database. Methods and Results— A national population-based study was performed using simulation and statistical process control. All patients who underwent cardiac surgery between January 1, 2007, and December 31, 2009, in all 16 cardiothoracic surgery centers in the Netherlands were included. Data on 46 883 consecutive cardiac surgery interventions were extracted. The expected risk factor frequencies were based on 2007 and 2008 data. Monthly frequency rates of 18 risk factors in 2009 were monitored using a Shewhart control chart, exponentially weighted moving average chart, and cumulative sum chart. Upcoding (ie, gaming) in random patients was simulated and detected in 100% of the simulations. Subtle forms of gaming, involving specifically high-risk patients, were more difficult to identify (detection rate of 44%). However, the accompanying rise in mean logistic European system for cardiac operative risk evaluation (EuroSCORE) was detected in all simulations. Conclusions— Statistical process control in the form of a Shewhart control chart, exponentially weighted moving average, and cumulative sum charts provide a means to monitor changes in risk factor frequencies in a clinical database. Surveillance of the overall expected risk in addition to the separate risk factors ensures a high sensitivity to detect gaming. The use of statistical process control for risk factor surveillance is recommended.

BackgroundInspiratory muscle training (IMT) before cardiac surgery has proved to be a promising intervention to reduce postoperative pneumonia in a randomized controlled trial setting. Effects of IMT in routine care have not been reported.ObjectiveThe purpose of this study was to investigate the effect of IMT before cardiac surgery on postoperative pneumonia in routine care at a Dutch university medical center using propensity scoring.DesignThis was an observational cohort study.MethodsAll candidates for cardiac surgery were preoperatively stratified by a physical therapist for low risk or high risk for postoperative pulmonary complications. Patients at high risk either engaged in an unsupervised IMT program (20 minutes a day) at home for at least 2 weeks before surgery (group 1) or received usual care (no IMT) (group 2). Results in terms of outcome measures were adjusted with propensity scores to reduce bias caused by nonrandom treatment assignment.ResultsThe results showed that of the 94 patients at high risk in group 1, 1 patient (1.1%) developed a postoperative pneumonia. In group 2, 8 out of the 252 patients at high risk (3.2%) developed this pulmonary complication (adjusted odds ratio=0.34, 95% confidence interval=0.04–3.38). No significant differences were found regarding median (25th–75th percentile) ventilation time (7 [5–9] hours versus 7 [5–10] hours), length of stay in the intensive care unit (23 [21–24] hours versus 23 [21–25] hours), or total postoperative length of stay (7 [6–11] days versus 7 [5–9] days).LimitationsThe most important limitations of this study were confounding, incomplete data collection, and a low incidence of the primary outcome.ConclusionsPropensity scoring is believed to be a valuable tool of great potential interest to researchers in the field of observational studies. Whether IMT in routine care resulted in less postoperative pneumonia cannot be concluded.

In 2007 The Netherlands Association for Cardio-Thoracic Surgery (Nederlandse Vereniging voor Thoraxchirurgie, NVT) instituted the Adult Cardiac Surgery Database. The dataset comprises demographic factors, type of intervention, in-hospital mortality and 18 risk factors for mortality after cardiac surgery, according to the European System for Cardiac Operative Risk Evaluation definitions. Currently, this procedural database contains over 60 000 interventions. Completeness of data is excellent and national coverage of all 16 Dutch cardio-thoracic surgery centres has been achieved since the start. The primary goal of the database is to control and maintain the quality of care by evaluation of outcomes. This is accomplished by regular feedback and comparison of outcomes. For a subset of the database (procedures from 10 out of 16 centres) longer-term follow-up has been established by means of data linkage to two national registries. This provides information on survival status, causes of death and readmissions. The database has recently been used for research, resulting in methodological papers aimed at optimizing comparison of outcomes. In future, clinical issues will also be addressed, for example survival after coronary artery bypass grafting and valve surgery.

Item does not contain fulltext A giant left atrial appendage is a rare congenital anomaly that has been reported on only a few occasions. We report two symptomatic patients with atrial fibrillation combined with a cerebellar infarct in one and dyspnea in the other. Both patients were treated surgically with resection of the giant left atrial appendage and radiofrequency pulmonary vein isolation. Recognition of this uncommon pathology can lead to timely surgical intervention. 01 oktober 2013

Objectives. This study was done to ascertain whether three-dimensional echocardiography can facilitate the diagnosis of mitral valve abnormalities.Background. The value of the additional information provided by three-dimensional echocardiography compared with two-dimensional multiplane transesophageal echocardiography for evaluation of the mitral valve apparatus has not been assessed.Methods. Thirty patients with a variety of mitral valve pathologies (stenosis in 8, insufficiency in 12, prostheses in 10) and 20 subjects with a normal mitral valve were studied. Images were acquired using the rotational technique (every 2°), with electrocardiographic and respiratory gating. From the three-dimensional data sets, cut planes were selected and presented in both two-dimensional format (anyplane echocardiography) and volume-rendered dynamic display. The data were compared with the original multiplane two-dimensional images. Different features of the mitral valve apparatus were defined and graded by three observers for clarity of visualization and confidence of interpretation as 1) inadequate, 2) sufficient, or 3) excellent.Results. All the techniques provided good visualization of the mitral valve (mean global scores ± SD for multiplane, anyplane and volume-rendered echocardiography were 2.22 ± 0.34. 2.24 ± 0.26 and 2.30 ± 0.25, respectively). With volume-rendered echocardiography, the mitral valve apparatus was scored higher in pathologic than in normal conditions (2.38 ± 0.24 vs. 2.16 ± 0.21, p < 0.002). The spatial relationships between the mitral valve and when structures. Reaflet mobility, commissures and orifice were scored higher by volume-rendered echocardiography. Prostheses were evaluated equally well by the three methods. Multiplane and anyplane echocardiography were superior for the evaluation of leaflet thickness, subvalvular apparatus and annulus.Conclusions. Transesophageal three-dimensional echocardiography facilitates imaging of some features of the mitral valve apparatus and provides additional information for comprehensive assessment of mitral valve abnormalities.