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Background: We sought to determine the long-term performance of homograft and truncal valve after complete repair of common arterial trunk., Methods: From January 1964 to June 2008, 32 patients (median age, 14 days; range, 5 days to 2.5 years) underwent primary homograft repair of common arterial trunk. Twenty-four (75%) were neonates. The homograft used in the right ventricular outflow tract was aortic in 24 patients and pulmonary in 8 patients (mean diameter, 15.8 +/- 3.5 mm; median diameter, 16 mm [range, 8-24 mm]). The median follow-up was 24.5 years (range, 5.6 months to 43.5 years)., Results: There were 3 hospital deaths and 1 late death. The actuarial survival at 30 years was 83.1% +/- 6.6%. Of the 28 survivors, 25 reoperations were performed in 19 (76%) patients. The mean and median times to homograft reoperation were 11.5 +/- 7.4 and 12.1 years (range, 1.0-26.1 years), respectively. Overall freedom from homograft reoperation after 10, 20, and 30 years was 68.4% +/- 8.7%, 37.4% +/- 9.5%, and 26.7% +/- 9.3%, respectively. Twelve patients retained the original homografts at a median follow-up of 16.4 years (range, 0-30.2 years). Six underwent a truncal valve replacement with a mechanical prosthesis at a median of 10.5 years (range, 3.4-22 years) after truncus repair. Freedom from truncal valve replacement at 10 and 30 years was 93.1% +/- 4.7% and 81.8% +/- 8.9%, respectively. In the 22 surviving patients who did not undergo truncal valve replacement, the peak truncal valve gradient was 8.9 +/- 8.3 mm Hg at a median follow-up of 24.5 years (range, 5.6 months to 32.9 years). At the last follow-up, 27 (96.4%) patients had good left ventricular function, and 24 patients (85.7%) were New York Heart Association class I., Conclusions: Oversizing the homograft at the time of the initial repair can lead to a homograft lasting more than 12 years. During long-term follow-up, 20% of patients require truncal valve replacement., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

The paper by Fratz et al. describes the follow-up of 188 children who had balloon aortic valvuloplasty (AoVP) between 1986 and 2004. Moderate or severe aortic regurgitation occurred more often in the 68 neonates--in whom there was significant early mortality--than in the 120 older children; however, AoVP produced a satisfactory reduction in aortic valve gradient in both groups. Reintervention-free status declined in both groups over time and, at 10 years follow-up, 59% of the neonates and 70% of the older group were intervention free. These results show that AoVP postpones the need for aortic valve surgery and has the advantage of being less invasive than initial surgical valvotomy. AoVP is, however, associated with an increased risk of aortic regurgitation and, in neonates, early subsequent aortic valve surgery is likely to be needed.

Background: Conducting system defects are common in patients with aortic valve disease. Aortic valve replacement may result in further conduction abnormalities and necessitate permanent pacemaker implantation (PPM). We sought to identify the contemporary incidence and predictors for early postoperative PPM in patients undergoing isolated aortic valve replacement., Methods: Data were analyzed from 354 consecutive patients undergoing isolated aortic valve replacement at a referral cardiac unit during a 30-month period; data were unavailable on 4 patients and a further 8 had undergone preoperative PPM. Results for the remaining 342 patients (97%; mean age, 67 +/- 14 years), of whom 212 were males, are presented. The major indications for aortic valve replacement were valvular stenosis (n = 224), regurgitation (n = 70), or infective endocarditis (n = 25). Preoperative conducting system disease was present in 26% of patients., Results: In-hospital mortality was 1.8% (6 of 342 patients). Postoperatively 29 patients (8.5%) required early PPM, of which 26 were during the index admission. Patients with preoperative conducting system disease (16% versus 6%; p = 0.004) and valvular regurgitation (16% versus 7%; p = 0.01) were more likely to require PPM as opposed to those without. Preoperative conducting system disease was the only independent predictor of PPM (p < 0.01); the relative risk of PPM requirement in this group was 2.88 (95% confidence interval, 1.31 to 6.33)., Conclusions: Permanent pacemaker implantation requirement after aortic valve replacement is a common occurrence, and should be discussed as part of the preoperative consent process. Preexisting conducting disease and preoperative aortic regurgitation were predictors of PPM requirement.

Background: Differences in sterilization, preservation, and implantation have been implicated in aortic allograft longevity. We report follow-up to 30 years of patients from a single unit who underwent aortic valve replacement with aortic allografts sterilized in antibiotics and refrigerated at 4 degrees C., Methods: Two hundred consecutive patients underwent subcoronary allograft aortic valve replacement and have been followed up to a minimum of 20 and maximum of 30 years. Follow-up was 96% complete. Parametric hazard phase modeling was used to identify incremental predictors of time-related risk., Results: Early mortality was 1.5%. Kaplan-Meier actuarial survival, including early death, was 81.2% +/- 2.8% (mean +/- standard error of the mean), 58.0% +/- 3.7%, and 52% +/- 5.1% at 10, 20, and 25 years, respectively. Freedom from reoperation for any reason was 86.4% +/- 2.6%, 39.6% +/- 5.2%, and 35.0% +/- 5.4% at 10, 20, and 25 years, respectively. Larger implanted valve, reexploration for bleeding, previous cardiac surgery, and operative rank were independent risks for reoperation. Early mortality in reoperations was 5.1%. Allograft endocarditis has occurred in 6 patients, giving an overall freedom of 94% at 25 years. Seven patients of the original cohort are known to be alive with their original allograft valve in situ, and of these the longest follow-up period is 29.8 years., Conclusions: The use of antibiotic-sterilized allografts for subcoronary aortic valve replacement confers low operative mortality and excellent long-term survival with durability matching any other nonmechanical device. Significantly reduced time-related risk of reoperation and excellent internal to external diameter ratio renders allograft aortic valve replacement especially ideal for smaller roots.

Objective: To assess the impact of early corrective surgery on the short and medium term outcome in tetralogy of Fallot (TOF)., Materials and Methods: All patients under 12 months of age undergoing correction of isolated TOF between February 1997 and July 2003 were reviewed retrospectively. Outcome data for mortality, post-operative care management, major morbidity and clinical follow-up were analysed., Results: Fifty-two operations were performed. The mean age at surgery was 5 months (range 1-12) of whom 16 (30.8%) were less than 3 months old, including 2 neonates, 22 (42.3%) were 3-6 months old and 14 (26.9%) were 7-12 months old. There was 1 (1.9%) early death caused by a cerebro-vascular accident and 1 (1.9%) late death secondary to acute infective endocarditis. There were no differences in post-operative morbidities attributable to age. Patients under 3 months old required greater duration of post-operative ventilation, ITU stay and in-hospital stay. At a mean follow-up of 4.0 years (range 1.5-8.0), 33 (63.5%) patients had well-tolerated pulmonary regurgitation (PR) and 3 (5.8%) patients required re-operation for right ventricular outflow tract obstruction (RVOTO). All patients had right bundle-branch-block but with QRS < 150 ms., Conclusion: Early definitive repair of TOF can be performed safely on patients under 6 months old. Age at surgery does not appear to affect the medium term haemodynamic outcome. However, early surgery does escalate the need for ICU care. This data suggests repair in asymptomatic patients be delayed until 3-6 months of age.

Acute myocarditis is characterized by the development of rapid life-threatening congestive heart failure and arrhythmias. In many cases with hemodynamic compromise, medical therapy and mechanical support alone are not sufficient. Various surgical procedures have been tried to bridge patients with myocarditis to both transplant and recovery. Mitral regurgitation is a frequent association with end stage cardiomyopathy and predicts poor outcome. Mitral annuloplasty is well-established in adults with ischemic and dilated cardiomyopathy and the results are superior to medical therapy alone and are comparable to cardiac transplantation. However, its effectiveness and use is not well-established in children with cardiomyopathy. We report our experience in two children.

Objective: The multi-national and multi-institutional collection of data on outcomes in Congenital Heart Surgery (CHS) provides the possibility of analysis of results of treatment and may result in further improvement of the quality of care. The verification of data as far as the completeness and accuracy is necessary to give confidence to all sides--the patients, centers and regulatory authorities. The source data verification (SDV), although difficult, appears possible even in such a large-scale database., Methods: Out of 5.274 patients and 5.612 procedures data of 2003, collected in the database, 1.703 (32.3%) and 1.895 (33.8%), respectively, have been verified at five sites on following fields: IPPV time, date of birth, date of admission, date of surgery, date of discharge/mortality, body weight, case category, CPB time, AoX time, Circulatory arrest time. SDV was performed at five sites by two database officers using the sources of information different to the local copy of the database (patients' files, operation notes, perfusion charts, OR Books). Verification was performed between June 1st and July 31st 2004. Statistical analysis was performed using R-project software, ver. 2.0.0. and Welch's t-test for comparison of continuous variables. P-value >0.05 was used as statistically significant difference between groups., Results: Pre- and post-verification mortalities in all groups showed no significant differences although seven deaths out of 68 (10.27%) were missed. None of the other verified fields showed significant differences after verification., Conclusions: Source Data Verification showed no statistically significant differences between verified and non-verified data on 30 days mortality, LOS, age, body weight, CPB time, AoX and Circulatory arrest time. IPPV time was not available in 58.6% procedures.

Objective: Leucocyte activation is central to end-organ damage that occurs during cardiac surgery under cardiopulmonary bypass (CPB). Exhaled nitric oxide (NO) increases in inflammatory lung conditions and has been proposed as a marker of pulmonary inflammation during CPB. This study examined the effect of leucodepletion on leucocyte activation, pulmonary inflammation and oxygenation in patients undergoing coronary revascularisation., Methods: Fifty low-risk patients undergoing first time coronary artery bypass graft (CABG) were randomised to two groups. Twenty-five patients had an arterial line leucocyte-depleting filter and 25 controls had a standard filter. Arterial blood samples were taken before CPB, 5 and 30 min on CPB, 5 min after aortic clamp removal and 6 h post-operatively. Activated leucocytes were identified with Nitroblue Tetrazolium staining. NO was sampled via an endotracheal teflon tube 15 min after median sternotomy before CPB and 30 min after discontinuation of CPB using a real-time chemiluminescense analyser. Respiratory index (alveolar-arterial oxygenation index, AaOI) was calculated before CPB, 1, 2, 4, 8 and 18 h post-operatively. Clinical outcome end-points were also recorded., Results: Total and activated leucocyte counts were significantly lower following leucodepletion during CPB (P < 0.0001). Exhaled NO rose significantly after CPB in the control group (3.8+/-1 ppb/s before CPB vs 5.6+/-2 ppb/s after CPB (P = 0.003) but not in the leucodepleted group (3.7+/-1 ppb/s before CPB vs 3.9+/-1 ppb/s after CPB (P = 0.051). AaOIs were consistently lower after leucodepletion (anova, P = 0.001). The duration of mechanical ventilation, the intensive care and hospital stay and the frequency of cardiac and respiratory complications were similar in the two groups., Conclusions: Leucodepletion reduces the numbers of circulating activated leucocytes and the pulmonary inflammation during CPB. This appears to limit lung injury and improve oxygenation in low-risk patients undergoing CABG surgery. Larger numbers of patients are required to evaluate the effect of continuous arterial line leucodepletion on the clinical outcome.

Objectives: Symptoms from low cardiac output or refractory atrial arrhythmias are complicating atriopulmonary (classical) Fontan connections. We present our experience of converting such patients to total cavopulmonary connections with and without arrhythmia surgery., Methods: Between 1997 and 2002, 15 patients (mean age, 19.7 +/- 7.0 years) underwent conversion operations 12.7 +/- 3.5 years after atriopulmonary Fontan operations. Preoperative New York Heart Association functional class was I in 2 patients, II in 2 patients, III in 6 patients, and IV in 5 patients. Four patients underwent intracardiac lateral tunnel conversion alone, and 11 received extracardiac total cavopulmonary connection, right atrial reduction, and cryoablation., Results: No mortality occurred. One patient had conduit obstruction in the immediate postoperative period requiring replacement, and another required a redo operation for endocarditis. Average hospitalization was 17.9 +/- 9.38 days; chest drains were removed on median day 4 (range, 1-29; mean, 7.4 +/- 7.58 days). At follow-up (mean, 42.6 +/- 22.1 months), late atrial arrhythmias had recurred in 3 of 4 patients with intracardiac total cavopulmonary connections (without ablation) and 1 of 11 patients with extracardiac total cavopulmonary connections with ablation. All patients are in New York Heart Association class I or II. Exercise ability (Bruce protocol) improved 69% from a mean of 6.18 +/- 4.01 minutes to 10.45 +/- 2.11 minutes (P <.05). Need for antiarrhythmic agents decreased postoperatively (patients receiving < or =1 antiarrhythmic: 9 preoperatively vs 15 at long-term follow-up, P <.05). No patient has required transplantation. Protein-losing enteropathy, which was present in 1 patient, improved transiently with conversion. There was 1 late death from gastrointestinal hemorrhage., Conclusions: Fontan conversion can be achieved with low mortality and improvement in New York Heart Association class and exercise ability. Concomitant arrhythmia surgery reduces the incidence of late arrhythmias.

Objective: The objective of this article is to evaluate the incidence of reoperation and the associated risk and survival after primary repair of congenital heart defects using cardiopulmonary bypass in children., Methods: We present a retrospective analysis of 1220 consecutive children under 16 years [649 (53%) under 1 year] operated on between 1976 and 2001 by 1 surgeon (J.L.M.)., Results: The early (30-day) mortality was 6.9%; 171 patients had 206 reoperations. The early mortality for the first reoperation was 10.4% and for second reoperation, 3.8%. Of the first-time reoperations 63% were inevitable, 15% were planned, and 22% were unexpected. The overall 20-year freedom from reoperation was 83% and survival (including early mortality) was 86%. The 10-year freedom from reoperation and survival, respectively, was as follows: aortic valvotomy, 77% and 92%; pulmonary valvotomy, 90% and 95%; atrial septal defect, 99% and 100%; partial atrioventricular septal defect (AVSD), 81% and 94%; complete AVSD, 74% and 70%; VSD, 95% and 97%; double-outlet right ventricle, 66% and 68%; truncus arteriosus, 54% and 71%; Mustard, 85% and 86%; arterial switch, 78% and 74%; Fontan, 77% and 66%; Fallot, 91% and 93%; and total anomalous pulmonary venous drainage, 89% and 84%. Of those undergoing aortic valvotomy, 53% were infants, but when aortic valve replacement became necessary an adult valve could be inserted. Introduction of the total cavopulmonary connection to the Fontan procedure in 1990 with prior cavopulmonary anastomoses has greatly improved outcome, with only 1 reoperation and no deaths since then. Patients with AVSD required 12 reoperations for mitral regurgitation, mostly through the "cleft," the closure of which in the past 5 years has provided promising results., Conclusions: The majority of reoperations after repair of congenital heart defects in children are inevitable, and their incidence varies for different types of procedures. These findings will help in informing parents about the possible outcome of surgery, but the introduction of newer techniques may reduce the need for reoperation further. The survival is encouraging.

Objective: The optimal time and approach of repair of tetralogy of Fallot (TOF) remain controversial. The purpose of this study was to evaluate the outcome following repair of TOF in infants with particular regard to the surgical approach used., Patients: One hundred and sixty infants (mean age 195+/-89 days, range 11-364 days) undergoing repair of a simple TOF were studied. Between 1974 and 2000, a transventricular approach (RV) was used in 91 and between 1988 and 2000, a transatrial (RA) approach in 69 infants. Ten of these infants (6.2%) had a previous palliative shunt (four in the RV versus six in the RA group). A transannular patch (TAP) was inserted in 96 (60%) infants (76 versus 20). Follow-up was complete (mean 14.5+/-5.2 versus 6+/-1 years)., Results: There were three operative deaths (1.9%), (two in RV versus one in RA group). A re-operation for right ventricular outflow tract obstruction (RVOTO) was performed in 19 patients (3 versus 16). Ten-year freedom from re-operation for RVOTO (+/-standard error of the mean) was 88+/-4% (98+/-2 versus 72+/-6%, P<0.0001). Within the RA group, 5-year freedom from re-operation for RVOTO for those who had a TAP was 79+/-9% and it was 75+/-4% for those having a simple repair. Six patients in the RV group required pulmonary valve replacement (PVR). Ten-year freedom from PVR was 98+/-1% (97+/-2 versus 100%, P=0.3). There were two late deaths, one in each group. Ten-year survival was 97+/-1%. One patient in the RV group developed late recurrent ventricular tachycardia requiring the implantation of a defibrillator. At most recent echocardiography, all but the patient who had the defibrillator had good right and left ventricular function., Conclusions: Transventricular and transatrial repair of TOF in infancy, are associated with an acceptable operative risk, low incidence of late arrhythmia, good bi-ventricular function and excellent survival. In our experience, however, transatrial repair has a disturbing incidence of early and mid-term residual or recurrent RVOTO, even when a TAP has been used.

Background and Aim of the Study: The study aim was to assess the risk of reoperation for patients with a failing stented tissue valve., Methods: Between 1980 and 1999, 259 patients (118 males, 141 females; mean age 60.1+/-15.4 years) underwent redo valve replacement to replace a failing stented tissue valve. Of these patients, 94 (36.3%) underwent redo aortic valve replacement (AVR), 105 (40.5%) redo mitral valve replacement (MVR), and 60 (23.2%) redo aortic and mitral valve replacement (DVR). Twenty patients (7.7%) had previous coronary artery bypass grafting (CABG); further CABG were performed in 32 cases (12.4%). Preoperatively, 216 patients (83.3%) were in NYHA functional class III or IV., Results: The early mortality was (6.5%; n = 17), including three patients who had AVR, five DVR, and nine MVR. A higher preoperative NHYA status (p <0.0004) and emergency surgery (p <0.0001) were significantly associated with an increased risk of operative death (univariate analysis). Age at surgery (p = 0.45), previous CABG (p = 0.45), position of the valve replaced (p = 0.2), type of implant (p = 0.06) and presence of coronary artery disease (p = 0.51) were not associated with a significant risk of operative mortality. Including those patients who died, 88 (34.0%) experienced a peri- or postoperative complication, seven of which (2.7%) were permanent., Conclusion: A failing tissue valve can be replaced, with acceptable operative mortality and morbidity. The choice of valve is a balance of its advantages and disadvantages, and these must be discussed with the patient. It appears, however, that the trend towards reducing the age at which tissue valve implantation is performed may be justified.

Background and Aim of the Study: Acute papillary muscle rupture (PMR) is a rare but fatal complication of myocardial infarction (MI). Surgery represents the best treatment option, but carries a high risk. Our experience of emergency mitral valve surgery in patients with acute PMR following MI during the past 22 years is reviewed., Methods: Between 1978 and 2000, 33 patients (20 males, 13 females; mean age 64 years; range: 46-80) underwent emergency surgery for acute post-infarct PMR in our institution. The site of MI was anterior in three patients and inferior in 30. Preoperatively, 17 patients had an intra-aortic balloon pump (IABP) inserted, 26 were on inotropic support, and 17 were ventilated. Twenty patients (61%) underwent concomitant coronary bypass grafting (CABG). The valve was replaced in 31 patients and repaired in two. Mean (+/- SD) duration of follow up was 63+/-54 months (range: 0-183 months)., Results: Early mortality (in-hospital) was 21% (n = 7). Factors associated with significant risk of early mortality included raised preoperative serum creatinine (p = 0.02), need for preoperative inotropic support (p = 0.03) and preoperative ventilation (p = 0.03). Raised preoperative serum creatinine remained significant on multiple logistic regression (p = 0.04). Postoperatively, 21 patients required an IABP. Mean duration of intensive care unit stay was 4+/-2.5 days (range: 0-10 days). Survival, including in-hospital mortality, at one, five and 10 years was 75+/-7.4, 65+/-8.6 and 32+/-9.7%, respectively. Four patients required valve-related reoperation (three for a paraprosthetic leak, one for failed repair)., Conclusion: Patients with acute post-infarct PMR present in a severely compromised state. Early mortality is high, but the intermediate outcome is encouraging for operative survivors.

Background: The purpose of this study was to evaluate the early and late clinical outcome after aortic root replacement (ARR) in patients with Marfan's syndrome., Methods: A total of 65 consecutive patients with Marfan's syndrome (mean age 41.7 +/- 10.7 years, range 15 to 76 years) undergoing ARR between 1972 and 1998 in Southampton were studied. Of the patients, 45 had a chronic aneurysm of the ascending aorta and 20 had a type A dissection (16 acute and 4 chronic). The operations were elective in 38 and nonelective in 27 cases (emergency in 22 and urgent in 5). Mean size of the ascending aorta was 6.3 +/- 1.4 cm (3.8 to 12 cm). A Bentall procedure was performed in 62 and a homograft root replacement in 3 patients. Mean follow-up was 8 +/- 4.1 years (0 to 22.9 years)., Results: Operative mortality was 6.1% (4 deaths) (for the elective vs nonelective procedures it was 2.6% vs 11%, p = 0.2). The 10-year freedom from thromboembolism, hemorrhage, and endocarditis was 88%, 89.8%, and 98.4% (0.9%, 0.9%, and 0.2% per patient-year) and from late aortic events it was 86.3% (1.3% per patient-year). Aortic root replacement for dissection was an independent predictor of occurrence of late aortic events (p = 0.01). Five patients had a reoperation with one early death. The 10-year freedom from reoperation was 89.2% (1.1% per patient year) (for elective and nonelective procedures, 90.8% vs 84.6%, p = 0.6). The 10-year survival, including operative mortality, was 72.7% (for elective and nonelective procedures, 78% vs 66.5%, p = 0.6). Late aortic events was an independent adverse predictor of survival (p = 0.02)., Conclusions: In patients with Marfan's syndrome, elective ARR, usually for chronic aneurysm, is associated with a low mortality, low rate of aortic complications, and good late survival. Nonelective ARR, mostly for dissection, has a greater operative risk and a significantly higher incidence of late catastrophic aortic events. Early prophylactic surgery in these patients is therefore recommended. Long-term clinical and radiologic follow-up to prevent or to treat late aortic events is highly desirable.

Objective: The most appropriate management of aortic stenosis (AS) in children remains controversial. The purpose of this study was to determine the outcome following open valvotomy for AS in children., Methods: Ninety-seven consecutive, unselected, children (mean age 3.2 +/- 3.6 years, 1 day--15 years) underwent an open valvotomy for critical (n=36) or severe (n=61) AS between 1979 and 2000 in Southampton. Twenty-six were neonates (1--31 days), 27 were infants (1--12 months) and 44 were older children (1--15 years). Mean follow-up was 10 +/- 5.4 years, 1 month--21.9 years., Results: Two neonates died early giving an overall operative mortality of 2.1% (7.7% for the neonates and 0% for infants and older children). The mean aortic gradient was reduced from 76 to 24.5 mmHg (P < 0.0001). Residual or recurrent AS occurred in 17 patients and severe aortic regurgitation in eight patients. Kaplan--Meier 10-year freedom from residual or recurrent AS was 83.1 +/- 4.7% and from severe aortic regurgitation was 95.3 +/- 2.7%. Twenty-five patients required an aortic re-operation or re-intervention, 18 of whom had an aortic valve replacement (AVR) (mean valve size 21.8 +/- 0.9 mm, range 21--25 mm). Ten-year freedom from any aortic re-operation or re-intervention was 78.4 +/- 5.2% and from AVR was 85.1 +/- 4.6%. There were ten late deaths. Overall 10-year survival, including hospital mortality, was 90.2 +/- 3.1% (69.7 +/- 9.7% for the neonates, 92 +/- 5.4% for the infants and 100% for older children, (P < 0.0001). Ten-year survival for children with isolated AS (n = 69) was 100% and for those with associated cardiovascular problems (n = 28) was 67.3 +/- 8.9% (P < 0.0001). All survivors are in New York Heart Association functional class I., Conclusions: Open valvotomy remains the gold standard in the management of AS in neonates, infants and older children. It is associated with low operative mortality and provides lengthy freedom from recurrent AS and regurgitation. Re-operations are common but if AVR is required, implantation of an adult-sized prosthesis is usually possible. There is a late death-hazard for those with severe associated lesions, but the survival prospects for the patients with isolated AS are excellent.

Background: In the absence of reliable national data, we have collected results of all operations for congenital heart defects from five departments to assess mortality rates and compare them among surgeons and departments., Methods: Data relating to all operations (2,718) carried out at the five centers during a period from April 1, 1997 through March 31, 1999. Clearly defined criteria were agreed for the classification of patients into various subgroups., Results: The overall hospital mortality was 4.4% (95% confidence intervals 3.7%-5.3%). Mortality for open-operations was 12.6% in neonates, 5.1% in infants, and 3.5% in children. Mortality rates were 1.1% for coarctation, 0.4% ventricular septal defect, 4.1% atrioventricular septal defect, 2.9% Fallot, 0.9% switch, and 15.6% truncus arteriosus. Although individual surgeons' mortality rates ranged from 1.8% to 7.5%, none of the 12 surgeons' data were above 95% confidence intervals. For individual surgeons, the change in mortality rates between the 2 years ranged between -3.3% and +3.8%., Conclusions: With 2 years' data available, estimates of mortality rates are more precise as reflected by tighter confidence intervals. There were relatively small data sets for individual hospitals and surgeons, which made statistical evaluation difficult. For setting standards, data from more departments for a longer period will be required. Statistical methods alone cannot be used as a sole arbiter of what is considered acceptable performance.

Objective: The purpose of this study was to assess the early and late outcome following mitral valve replacement (MVR) with mechanical prostheses in children., Patients and Methods: Between 1981 and 2000, 44 consecutive children (mean age 6.8+/-4.7 years, 2 months--16 years) underwent mechanical MVR in Southampton. Twenty-three children were less than 5-years-old and nine were infants. Disease aetiology was congenital in 37, rheumatic in four, infective in two and Marfan's syndrome in one. Mitral regurgitation was present in 36 and mitral stenosis in eight. Concomitant procedures were performed in 13, including aortic valve replacement (AVR) in seven. Follow-up was complete (mean 6.4+/-4.8 years, 1 month--18.1 years)., Results: The overall operative mortality was 14% (six patients). Before and after 1990 operative mortality was 31 vs 3.6% (P=0.02). From 1990, operative mortality for infants was zero out of six, for children less than 5-years-old was one out of 16 (one death after emergency AVR and MVR) and for older children it was 0/12. Seven children experienced valve or anticoagulation treatment-related events and eight had a mitral valve re-operation. Ten-year freedom from thromboembolism, prosthetic valve infection, bleeding, paravalvular leak and a mitral valve re-operation was 92.8+/-5.2, 97.3+/-2.7, 97.7+/-2.3, 97.2+/-2.7 and 75+/-9.7%, respectively. Overall 10-year survival was 78+/-7% (four late deaths); for children under vs over 5 years it was 61+/-11 vs 95.2+/-4.6% (P=0.02), for atrio-ventricular septal defect (AVSD) vs other pathology 55+/-15 vs 89+/-6.1% (P=0.05) and for those operated before 1990 vs after 1990 it was 63+/-8.1 vs 86+/-8.2% (P=0.04)., Conclusions: Mechanical MVR, in the current era, carries a low operative risk across the spectrum of paediatric age. Late survival is better for older children and those having no-AVSD pathology but it has improved substantially during the 1990s irrespective of age and disease aetiology.

Background: To evaluate the fate of the truncal valve, the antibiotic sterilized aortic homografts, and the survival after repair of truncus arteriosus in the first 6 months of life., Methods: Between 1974 and 1994, 23 infants (mean age 1.7 months, range 5 days to 6 months) underwent primary repair of truncus arteriosus by one surgeon (J.L.M). Sixteen were neonates (age range 5 to 30 days). Continuity between the right ventricle and the pulmonary artery was established with an aortic antibiotic sterilized homograft (mean diameter 14.9 mm, range 11 to 17 mm). Follow-up was 100% complete., Results: Four neonates with severe truncal regurgitation died early (17.4%). Fourteen patients underwent reoperations. Five had a truncal valve replacement (mean time 7 years, range 6 months to 17 years). Ten-year freedom from truncal valve replacement was 78.2%. Eleven patients had homograft replacement (mean time 12.7 years, range 2 to 26.2 years). Ten-year freedom from homograft replacement for any cause was 77.1% (for homograft-related problems it was 86.7%). Seven patients retained the original homografts (mean time 14.3 years, range 6 to 18.7 years). There was one late death. Overall 10-year survival was 79% and for the hospital survivors it was 95%. All survivors are in New York Heart Association functional class I., Conclusions: Abnormal truncal valves pose serious early and late problems but the patients with normal truncal valves do well and seem unlikely to need replacement of these valves. The durability of the antibiotic sterilized aortic homograft even in sizes less than 14 mm is remarkably good. Late survival is excellent.

Introduction: 10% of blood issued by the National Blood Service (220,000) is utilised in cardiac procedures. Transfusion reactions, infection risk and cost should stimulate us to decrease this transfusion rate. We tested the efficacy of autotransfusion of washed postoperative mediastinal fluid in a prospective randomized trial., Patients and Methods: 166 patients undergoing coronary artery bypass grafting (CABG), valve or CABG + valve procedures were randomized into three groups. The indication for transfusion was a postoperative haemoglobin (Hb) < 10 g/l or a packed cell volume (PCV) < 30. When applicable, group A patients received washed post-operative drainage fluid. Group B all received blood processed from the cardiopulmonary bypass (CPB) circuit following separation from CPB and if appropriate washed post-operative drainage fluid. Group C were controls. Groups were compared using analysis of variance., Results: There was no significant difference in age, sex, type of operation, CPB time and preoperative Hb and PCV between the groups. Blood requirements were as shown. [table - see text] Twelve patients in group A and 10 in group B did not require a homologous transfusion following processing of the mediastinal drainage fluid., Conclusion: Autotransfusion of washed postoperative mediastinal fluid can decrease the amount of homologous blood transfused following cardiac surgery. There was no demonstrable benefit in processing blood from the CPB circuit as well as mediastinal drainage fluid.

Background: Modified Blalock-Taussig (BT) shunt causing pulmonary artery distortion has been reported. This distortion may get worse after a corrective operation if the BT shunt is ligated, rather than divided. In this study we examined whether division of modified BT shunt at the time of corrective operation would allow pulmonary artery growth and avoid further distortion., Methods: Fifteen patients who had modified BT shunts and subsequently had corrective operations performed by one surgeon between January 1980 to December 1990 were analyzed. The median time from the BT shunt to corrective operation was 46.3 months (range, 3 to 119 months). At the time of corrective procedure, the BT shunt was divided and metal clips were used to occlude and mark each end. At follow-up a chest roentgenogram was obtained and the distance between the two clips was measured., Results: In all 15 patients measured sequentially the distances between the two clips increased steadily., Conclusions: Division of BT shunt at the time of corrective procedure reduces pulmonary artery distortion.

Background: The optimal management of critical aortic stenosis in early infancy remains controversial. The aim of this study was to assess the early and late outcomes following open surgical valvotomy for critical aortic stenosis in neonates and to provide a framework of data against which current results of other treatment approaches can be evaluated., Methods: Eighteen consecutive neonates (mean age 9.2 days, range 1 to 26 days) undergoing an open valvotomy for critical isolated aortic stenosis (the standard treatment for this condition in our unit) between 1984 and 2000 were studied. The mean aortic valve gradient was 79.4 mm Hg. Twelve neonates received prostaglandins and 10 received inotropic agents preoperatively. Follow-up was complete (mean 8.1 years, range 1 month to 15 years)., Results: There was no operative mortality. At discharge, the mean aortic valve gradient was 37.2 mm Hg, with 6 patients having mild and 2 having moderate aortic regurgitation. Six patients required a reoperation; 3 of these had an aortic valve replacement at 9 to 11 years of age. Kaplan-Meier 5- and 10-year freedoms from any aortic reoperation or reintervention were 85 and 55%, respectively; 5- and 10-year freedoms from aortic valve replacement were 100 and 79%, respectively. A 14-year-old boy died from endocarditis 4 years following an aortic valve replacement in another unit. Kaplan-Meier 10-year survival was 100%. All survivors are in New York Heart Association I class and are leading normal lives. Their mean aortic valve gradient is 34.5 mm Hg, and none has significant aortic regurgitation., Conclusions: Open valvotomy for critical aortic stenosis in neonates carries a low operative risk and provides lengthy freedom from recurrent stenosis or regurgitation. Reoperations are inevitable, but aortic valve replacement can be delayed until the implantation of an adult-sized prosthesis is possible. Late survival is excellent. We consider open surgical valvotomy to be the treatment of choice for critical neonatal aortic stenosis.

Background: The purpose of this study was to evaluate the early and late outcome after repair of tetralogy of Fallot in the first year of life., Methods: Between 1974 and 2000, 89 consecutive infants with a mean age of 6.3 +/- 2.6 months (range, 15 days to 12 months) underwent repair of tetralogy of Fallot (ventricular septal defect and pulmonary stenosis) by one surgeon (J.L.M.). Three infants had previous palliative operations. Sixty-seven procedures were urgent or emergency. A transannular patch was inserted in 69 patients (77.5%). Follow-up was complete, averaging 13.4 +/- 5.6 years (range, 0 to 25.4 years)., Results: There was one operative death (1.1%). Mean right ventricular to left ventricular pressure ratio postoperatively was 0.4 +/- 1.1 (in 79 patients, < 0.5). Fourteen patients underwent reoperations or reinterventions. There were no reoperations for residual or recurrent ventricular septal defect. Kaplan-Meier freedom from reoperation or reintervention for any cause at 20 years was 85% +/- 4.4%, for relief of right ventricular outflow tract obstruction it was 94% +/- 3.1%, and for pulmonary valve replacement this was 95.4% +/- 2.6%. Use of a transannular patch did not significantly affect the need for reoperation or reintervention. There was one late death (leukemia). Kaplan-Meier 20-year survival was 97.8% +/- 1.9%. On latest echocardiography, 42 patients had moderate pulmonary regurgitation, 4 had a right ventricular outflow tract gradient more than 40 mm Hg, and 86 had good biventricular function. Twelve-lead electrocardiography was performed in all and 24-hour electrocardiography in 61 patients. One patient (1.1%) exhibited late recurrent ventricular tachycardia requiring implantation of a defibrillator. The remaining 86 patients are in New York Heart Association class I with none of them receiving antiarrhythmic medications., Conclusions: These data strongly support the concept of early repair of tetralogy of Fallot. It is associated with an acceptable operative risk and a low incidence of significant arrhythmias, and provides long-term survival similar to that observed in the general population. Late complications may, however, develop, and long-term follow-up for their early recognition is essential.

Background and Aim of the Study: The study aim was to determine risk factors for operative mortality, recurrent infection, reoperation and long-term survival following aortic valve replacement (AVR) for infective endocarditis., Methods: Between 1973 and 1997, 109 patients (91 male, 18 female, mean age 52.6 years) underwent isolated AVR for infective endocarditis in our unit. Native valve endocarditis was present in 89 (81.6%) and prosthetic valve endocarditis in 20 (18.4%). Active culture-positive endocarditis was present in 53 (48.6%). Preoperatively, 99 patients (90.8%) were in NYHA classes III and IV. Indications for surgery included cardiac failure in 41 patients, valvular dysfunction in 38, vegetations in 18, sepsis in seven, abscess in six and embolism in four. Mechanical valves were implanted in 69 patients (63.3%) and bioprostheses in 40 (36.7%), including a homograft in 19 (17.4%). Follow up was complete (mean 5.8 years; range: 0-23.8 years; total 633.5 patient-years)., Results: The operative mortality was 10.1% (11 deaths). At ten years, freedom from recurrent infection was 94.2%, and freedom from reoperation 83.6%. Biological valve and younger age were significant adverse parameters for freedom from reoperation (p = 0.01 and p = 0.01). There have been 21 late deaths, 15 due to cardiac causes. Kaplan-Meier survival, including operative mortality, at five and ten years was 77.4% and 68.0%, respectively. On Cox proportional hazards regression, Staphylococcus aureus infection (p = 0.008) and older age (p = 0.04) were independent adverse predictors of survival., Conclusion: AVR for endocarditis carries a relatively high operative mortality, but can result in a satisfactory freedom from recurrent infection, reoperation and long-term survival. Analysis of our series demonstrates that implantation of a biological valve limits the freedom from reoperation and that infection by Staph. aureus reduces the probability of long-term survival.

Background: The purpose of this study was to describe a single unit experience in the surgical treatment of active culture-positive endocarditis and identify determinants of early and late outcome., Patients and Methods: One hundred eighteen consecutive patients with positive blood culture up to 3 weeks before operation (or positive valve culture) and macroscopic evidence of lesions typical for endocarditis, undergoing operation between January 1973 and December 1996 in Southampton, were evaluated. The aortic valve was infected in 53 (48.9%), the mitral in 46 (39%), both aortic and mitral in 12 (10.1%), the tricuspid in 4 (3.9%), and the pulmonary valve in 3 (2.5%). Native valve endocarditis was present in 83 (70.3%) and prosthetic valve endocarditis in 35 (29.7%). Streptococci and staphylococci were the most common pathogens. Mean follow-up was 5.6 years (range, 0 to 25 years)., Results: Operative mortality was 7.6% (9 patients). Endocarditis recurred in 8 (6.7%). A reoperation was required in 12 (10.2%). There was 24 late deaths, 17 of them cardiac. Actuarial freedom from recurrent endocarditis, reoperation, late cardiac death, and long-term survival at 10 years were 85.9%, 87.2%, 85.2%, and 73.1%, respectively. On multiple regression analysis the following were independent adverse predictors: pulmonary edema (p = 0.007) and impaired left ventricular function (p = 0.02) for operative mortality; prosthetic valve endocarditis (p = 0.01) for recurrent infection; myocardial invasion by the infection (p = 0.01) and reoperation (p = 0.04) for late cardiac death; and coagulase-negative staphylococcus (p = 0.02), annular abscess (p = 0.02), and longer intensive care unit stay (p = 0.02) for long-term survival., Conclusions: Operation for active culture-positive endocarditis carries an acceptable mortality. Freedom from recurrent infection, reoperation, and long-term survival are satisfactory. In our data, patients' hemodynamic status at operation was the major determinant of operative mortality. Prosthetic valve endocarditis, coagulase-negative staphylococcus, and annular or myocardial infectious invasion were the critical adverse determinants of late outcome.

Background and Aim of the Study: The CarboMedics bileaflet prosthetic heart valve was introduced in 1986, and first implanted by the authors in March 1991. The aim of this study was to analyze the authors' clinical experience with this valve., Methods: Between March 1991 and October 1998, 1,503 valves were implanted in 1,350 patients (758 males, 592 female; mean age 62 +/- 13 years). Follow up was 99% complete and totaled 4,342 patient-years (pt-yr)., Results: The hospital mortality rate was 4.3% (59/1,350). Preoperative NYHA class (p = 0.012), emergency surgery (p = 0.03) and cardiopulmonary bypass time (p = 0.01) were significantly associated with increased risk of operative death (multiple logistic regression). Mean (+/- SEM) survival rates at one and five years were 92.0 +/- 0.7% (n = 1,109) and 80.0 +/- 1.3% (n = 335). Freedom from valve-related complications (linearized rate 5.6%/pt-yr) at one and five years was 89.5 +/- 0.8% (n = 1,031) and 76.3 +/- 1.4% (n = 284). Linearized rates for bleeding events were 2.19%/pt-yr, thromboembolic events 2%/pt-yr, operated valvular endocarditis 0.18%/pt-yr, valve thrombosis 0.14%/pt-yr and non-structural dysfunction 1.22%/pt-yr. Freedom from reoperation at one and five years was 98.5 +/- 0.3% (n = 1,107) and 97.3 +/- 0.5% (n = 334)., Conclusion: Mid-term results demonstrate that the CarboMedics prosthetic heart valve exhibits a low incidence of valve-related complications.

Background and Aims of the Study: The study aim was to review our experience in surgical treatment of infective mitral valve endocarditis, and to identify predictors of early and late outcome., Methods: Ninety-one consecutive patients (52 males, 39 females, mean age 55.6 years) underwent surgery between 1973 and 1997 for endocarditis of isolated mitral (n = 65, 71%), mitral and aortic (n = 25, 28%) and mitral, aortic and tricuspid valves (n = 1, 1%). Native valve endocarditis (NVE) was present in 60 patients (66%) and prosthetic valve endocarditis (PVE) in 31 (34%). The main indications for surgery were heart failure in 32 patients, valve dysfunction in 23, vegetations in 21, and persistent sepsis in 11. Eighty-six patients (95%) were in NYHA classes III-IV, and 58 (64%) had active culture-positive endocarditis at surgery. Mechanical valves were implanted in 73 patients and bioprosthetic valves in 13; valves were repaired in five patients. The impact of 46 parameters on early and late outcome was defined by means of univariate and multivariate statistical analysis. Follow up was complete (mean 5.5 years; range: 0-23.1 years; total 507.3 patient-years)., Results: Operative mortality rate was 11% (n = 10). Recurrent infection was recorded in five patients (6%), and reoperation was required in eight (9%). Freedom from recurrent infection and reoperation at 10 years was 89.1% and 87.8% respectively. There were 22 late deaths, 15 from cardiac causes. Actuarial survival rates for all patients at 5, 10 and 15 years were 73.0%, 62.7% and 58.7% (for hospital survivors, the corresponding rates were 81.9%, 69.7% and 66.0%). On multiple logistic regression and Cox proportional hazards models, the following were independent predictors: preoperative pulmonary edema (p = 0.01) for operative mortality; PVE (p = 0.02) for recurrence; younger age (p = 0.02) and PVE (p = 0.02) for reoperation; male gender (p = 0.004) and longer ITU stay for survival (if all patients were included); male gender (p = 0.01) and myocardial invasion by infection (p = 0.02) for survival (if only the hospital survivors were analyzed)., Conclusion: Surgery for infective mitral valve endocarditis carries a relatively high, though acceptable, risk but provides satisfactory freedom from recurrent infection, reoperation and improved long-term survival. Analysis of these data demonstrated that the preoperative hemodynamic status was the major predictor of in-hospital outcome, PVE increased the risk for recurrent infection and reoperation, whereas male gender and myocardial invasion by the infective process critically reduced the probability of long-term survival. The type of offending pathogen, the activity of infection and the involvement of more than one valve did not appear to influence early and/or late outcome.

Objective: To evaluate the extent of intrapulmonary right to left shunting in children after bidirectional cavopulmonary anastomosis (BCPA)., Design: Prospective study of patients who underwent BCPA in a single centre., Patients: 17 patients with complex cyanotic congenital cardiac malformations who underwent BCPA at 1-45 months of age (median 21 months) were evaluated 15-64 months postoperatively (median 32 months). Five children between 1 and 10 years (median 5 years) with normal or surgically corrected intracardiac anatomy and peripheral pulmonary circulation who required V/Q scanning for other reasons were used as controls., Interventions: All patients underwent cardiac catheterisation to exclude angiographically demonstrable venovenous collaterals followed by pulmonary perfusion scanning using (99m)technetium ((99m)Tc) labelled albumen microspheres to quantify the intrapulmonary right to left shunt., Main Outcome Measure: Percentage of intrapulmonary right to left shunt., Results: The mean (SD) level of physiological right to left shunting found in the control group was 5.4 (2.3)%. All patients with BCPA showed the presence of a significantly higher level of intrapulmonary shunting (26.8 (16.9)%, p < 0.001). The degree of shunting was significantly increased in the subgroup of 11 patients with BCPA as the only source of pulmonary blood flow (34.9 (15.8)%), when compared to the six remaining patients with an additional source of pulmonary blood supply (12.0 (2.6)%, p < 0.001). There was a negative correlation between age at BCPA and the shunt percentage found in the patients with a competitive source of pulmonary blood flow (r = -0.63, p < 0. 01)., Conclusions: Intrapulmonary right to left shunting develops in all patients following BCPA. This may be caused by a sustained and inappropriate vasodilatation resulting from absence or decreased levels of a substance that inhibits pulmonary vasodilatation. Augmenting BCPA with an additional source of blood flow containing hepatic factor limits the degree of intrapulmonary arteriovenous shunting and may help provide successful longer term palliation.

Background: The CarboMedics bileaflet prosthetic heart valve was introduced in 1986. We first implanted it in March 1991. The purpose of this study was to analyze our clinical experience with this valve., Methods: Between March 1991 and December 1997, 1,378 valves were implanted in 1,247 patients, 705 men (56.5%) and 542 (43.5%) women with a mean age of 62 +/- 11.9 years (+/- the standard deviation). Follow-up is 99% complete and totals 3,978 patient-years., Results: The early mortality rate was 4.4% (55/1,247). The survival rates at 1 year and 5 years were 91.8% +/- 0.8% (+/- the standard error of mean) (n = 1,062) and 79.2% +/- 1.4% (n = 281), respectively. Freedom from valve-related complications (linearized rate, 4.9% per patient-year) at 1 year and 5 years was 90.6% +/- 0.8% (+/- the standard error of the mean) (n = 996) and 80.6% +/- 1.4% (n = 243), respectively. Linearized rates for various complications were as follows: bleeding events, 1.73% per patient-year; embolic events, 1.76% per patient-year; operated valvular endocarditis, 0.18% per patient-year; valve thrombosis, 0.10% per patient year; and nonstructural dysfunction, 1.21% per patient-year. Freedom from reoperation at 1 year and 5 years was 98.6% +/- 0.3% (+/- the standard error of the mean) (n = 1,070) and 97.7% +/- 0.5% (n = 285), respectively., Conclusions: Midterm results demonstrate that the CarboMedics prosthetic heart valve exhibits a low incidence of valve-related complications.

Objective: The choice of the most appropriate substitute in children with irreparable aortic valve lesions remains controversial. The aim of this study was to assess early and late outcomes following aortic valve replacement (AVR) with mechanical prostheses in children., Patients: Fifty-six patients (42 male, 14 female, mean age 11.2, range 1-16 years) undergoing AVR with mechanical prostheses between October 1972 and January 1999 were evaluated. Thirty-six patients (64.2%) underwent previous cardiac surgery. Disease aetiology was congenital in 47 patients (congenital aortic stenosis in 33, and other congenital abnormalities in 14) (83.9%), infective in four (7. 1%), rheumatic in two (3.4%), and three (5.3%) had connective tissue disorders. Haemodynamic indication for AVR was aortic regurgitation (AR) in 24 (42.8%), aortic stenosis (AS) in 22 (39.2%) and mixed disease in ten (17.8%). Twenty-eight patients (50.0%) were in New York Heart Association (NYHA) class III-IV before surgery. Concomitant procedures were performed in 31 patients (55.3%), including aortic root enlargement in 28 (50%). The mean size of implanted valves was 22.4 mm (range 17-27 mm). All patients received long-term anticoagulation treatment with sodium warfarin, aiming to maintain an international normalized ratio (INR) between 2.5-3.0. The mean follow-up was 7.3 years (range 0-26, total 405 patient-years)., Results: Operative mortality was 5.3% (three patients). Three patients developed complete heart block requiring pacing, two of them permanently. Late events included valve thrombosis (one), transient stroke (one), paravalvular leak of a mitral prosthesis (one), aneurysm of sinus of Valsalva (one) and pannus ingrowth (one). There was no major haemorrhagic event. Five patients required re-operation (8.9%), but none due to outgrowth of the valve. Regarding actuarial freedom from thrombo-embolism, any valve-related event and re-operation at 20 years was 93, 86.6 and 86. 4%. There were three late deaths. Actuarial survival, including operative mortality, at 10 and 20 years was 91 and 84.9%. The actuarial survival for the group of the patients with congenital AS (n=33) at 10 and 20 years was 93.5%, whereas for the children with other congenital heart problems (n=14) this was 85.7 and 64.3% (P=0. 09). At the latest clinical evaluation, 44 children were in NYHA class I and six were in class II. The mean gradient across the aortic prosthetic valve on echocardiography was 17.9 mmHg (range 0-47 mmHg)., Conclusions: Mechanical AVR, with enlargement of the aortic root if necessary, remains an excellent treatment option in children. It is associated with acceptable operative mortality, low incidence of late events and re-operation, and provides good long-term survival. It clearly represents a good alternative to available biological substitutes, including the pulmonary autograft (Ross procedure).

Objective: Between 1977 and 1988, 27 patients, mean age 8.9 (range 4-22) received an antibiotic sterilised aortic allograft in the setting of the Fontan procedure. This study describes the long-term follow-up of these patients., Methods: Fifteen patients had tricuspid atresia, nine double inlet ventricles and three others. The connection with the allograft was made to the pulmonary artery on the right side of the aorta in ten and to a left-sided main pulmonary artery in eight. In nine patients the allograft was anastomosed between the right atrium and the right ventricle., Results: There were five early and five late deaths. One late death may have been allograft related. Survival was 81, 74 and 68% at 5, 10 and 15 years, respectively. Conduit calcification was universal. Twelve patients underwent reoperation, freedom from reoperation was 100, 88 and 54% at 5, 10 and 15 years following the initial Fontan procedure. At reoperation the gradient across the allograft was never more than 3 mmHg. The allograft was explanted with conversion to atriopulmonary or cavopulmonary connection in nine and a second allograft was inserted between the right atrium and right ventricle in two. No mortality occurred at reoperation. 41.1% of survivors still have their original allograft., Conclusions: Although there is a significant attrition rate allograft inclusion in the Fontan circulation does not change survival, but results in an increased reoperation rate. Inclusion of a valved conduit between the right atrium and ventricle does not usually enhance the growth potential of the rudimentary ventricle. All patients are in a good functional class which may represent the strict original selection criteria. The inclusion of a valve in the Fontan circulation is not recommended.

Objective: Surgery for endocarditis in children is relatively uncommon. Our aim is to assess operative mortality, recurrent infection, re-operation and long-term survival rates following surgery for infective valve endocarditis in children., Patients: Sixteen consecutive children (ten female, six male, mean age 11.8 years, range 25 days-16 years) undergoing surgery between 1972 and 1999 in Southampton were studied. The aortic valve was affected in five, mitral in four, aortic and mitral in one, tricuspid in five and a pulmonary homograft in one patient. Prosthetic valve endocarditis was present in three. Twelve surgical interventions were emergency and four urgent. Indications for operation included cardiac failure in five, severe valvular dysfunction in nine, vegetations in nine, persistent sepsis in four and embolization in four patients. The offending micro-organism was identified in 13. Valve replacement was performed in 11 and excision of vegetations in two and excision of vegetations and repair in three. Follow-up was complete (mean 11.2 years, range 2 months to 26.3 years, total 179.5 patient years)., Results: There was one operative death (6.2%) in a 25-day-old neonate who presented in a moribund condition. Endocarditis recurred in one patient (6.25%). Freedom from recurrent infection at 10 and 20 years was 100.0 and 87.5%. Seven surgical re-interventions were required in four (25.0%) patients with no operative mortality. Freedom from re-operation at 1, 5, 10 and 20 years, was 84.6, 76.1, 76.1 and 60.9%, respectively. Two patients died 15 and 23 years after their first operation. The cause of the late deaths was non-cardiac in the first and unknown in the other. Actuarial survival, including operative mortality, at 1, 15 and 20 years was 93.7, 93.7 and 78.1%., Conclusions: Surgery in children with infective valve endocarditis can be performed with low operative mortality. Although some patients may require re-operation, freedom from recurrent infection and long-term survival are satisfactory.

Objective: We report the combined early results from two centers in the United Kingdom using a composite conduit consisting of a bileaflet mechanical valve incorporated into a gelatin-impregnated, ultra-low porosity, woven polyester graft (Carbo-Seal; Sulzer Carbomedics, Inc, Austin, Tex)., Methods: Between August 1992 and March 1997, 143 patients underwent aortic root replacement with the Carbo-Seal composite prosthesis. The indication for surgery was acute type A dissection in 31 (22%), chronic type A dissection in 9 (6%), ascending aortic aneurysm without dissection in 100 (70%), and false aneurysm of the ascending aorta in 3 (2%). Twenty-seven patients (19%) had undergone previous sternotomy, and 40 (28%) were seen as emergencies. Concomitant procedures were performed in 38 (27%), including 18 aortic arch or hemiarch replacements. Total follow-up is 270 patient-years. Follow-up is 100% complete., Results: The early (30-day) mortality was 7% (10 patients). Permanent neurologic events occurred in 2%. At a mean follow-up of 23 months, 94% of survivors were in New York Heart Association functional class I. Freedom from reoperation was 97.2% +/- 1.6% (1 standard error [1 SE]) at 12 months and 95.7% +/- 2.2% at 48 months. Including early mortality, survival was 90.1% +/- 2.6% at 12 months and 83.1% +/- 3. 5% at 48 months., Conclusions: Aortic root replacement with use of the Carbo-Seal prosthesis can be undertaken with a relatively low early mortality and morbidity. A low reoperation rate and high intermediate-term survival can be expected, but continued follow-up is needed to determine the long-term efficacy of this prosthesis.

Background and Aim of the Study: Tricuspid valve replacement (TVR) is rarely undertaken, most surgeons preferring to use conservative tricuspid valve procedures. Thus, limited data are available in patients following TVR. The purpose of this study was to analyze the early and late results in 87 patients (52 tissue valves, 35 mechanical prostheses) who underwent TVR between January 1973 and September 1996., Methods: The patient group comprised 74 (85%) females and 13 (15%) males; mean (+/- SD) age was 59.4 +/- 12.8 years; range: 15 to 81 years). Forty-four patients (51%) had undergone at least one previous cardiac operation. There were 19 (23%) isolated TVRs, 43 (49%) triple valve replacements, and 25 (29%) double valve replacements. Total cumulative follow up was 707 patient-years (pt-yr) (tissue valves 393 pt-yr, mechanical valves 314 pt-yr); mean follow up was 8.1 years (range: 0 to 23.6 years)., Results: The early (30-day) mortality rate was 10.3% (n = 9; tissue 7, mechanical 2, p = 0.28). Logistic regression identified prolonged cardiopulmonary bypass time (p <0.03) and advanced NYHA functional class (p <0.007) as risk factors for operative death. No risk factors were significant on multiple logistic regression analysis. Mean (+/- SEM) survival rate was 68 +/-5.3% (n = 50) at 5 years, 52 +/- 5.9% (n = 36) at 10 years, 35 +/- 6% (n = 20) at 15 years, and 16 +/- 5.3% (n = 7) at 20 years. Freedom from tricuspid valve reoperation at 5, 10 and 15 years was 93 +/- 3.3% (n = 46), 83 +/- 5.8% (n = 33) and 71 +/- 2.8% (n = 17) respectively. Eleven patients required tricuspid valve reoperation: six mechanical valves (five for prosthetic valve thrombosis and one for mechanical failure secondary to pannus ingrowth), and five tissue valves (two for prosthetic valve endocarditis and three for prosthetic valve degeneration). Freedom from reoperation at 5, 10 and 15 years for tissue prostheses was 97 +/- 2.5%, 89 +/- 6.3% and it was 70 +/- 12%, and 86 +/- 7.4%, 74 +/- 9.9% and 68 +/-11% for mechanical prostheses. The mechanical prostheses required reoperation earlier after the initial surgery., Conclusions: We recommend the use of a bioprosthesis in the tricuspid position because of its initial durability and low reoperation rate.

An 8 year old child with tricuspid atresia had developed right sided pulmonary arteriovenous malformations following a previous classic Glenn procedure. These became clinically manifest immediately after Fontan conversion because of severe systemic desaturation. The pathophysiology and postoperative medical management of this case is described and related to current understanding of the aetiology of acquired pulmonary arteriovenous malformations following cavopulmonary shunt.

The aim of this study was to determine long-term results from one unit of subcoronary homograft aortic valve replacement (AVR) using the same sterilization and preservation techniques in each case. Between 1973 and 1983, 200 patients underwent AVR using an unstented homograft previously sterilized in antibiotics and preserved at 4 degrees C. Surviving patients were monitored for a minimum of 15 years to the end of 1998. Mean age was 50.0+/-14 (1 standard deviation) years; 121 patients were men (60.5%). Mean patient follow-up time was 15.6+/-6.7 years, with a total follow-up time of 3,115 patient years. Follow-up was 95.6% complete. There were three early deaths (1.5%). At autopsy, the homograft was anatomically normal and in a satisfactory position. Kaplan-Meier survival, including early death, was 81.2%+/-2.8% (1 standard error) at 10 years, 68.1%+/-3.4% at 15 years, and 58.0%+/-3.7% at 20 years. Repeat AVR was undertaken in 74 patients, giving a freedom from reoperation for any reason of 86.5%+/-2.6%, 69.6%+/-3.8%, and 38.8%+/-5.3% at 10, 15, and 20 years, respectively. Freedom from structural valve degeneration at 10, 15, and 20 years was 81.1%+/-2.9%, 61.7%+/-3.9%, and 31.2%+/-4.7%, respectively. Freedom from endocarditis at 10, 15, and 20 years was 98.7%+/-0.9%, 96.0%+/-1.8%, and 94.6%,+/-2.3%, respectively. Homograft AVR with an antibiotic-sterilized valve stored at 4 degrees C and implanted in the subcoronary position offers low operative mortality and good long-term outcome for patients.