IRANIAN JOURNAL OF CARDIAC SURGERY
Year:2010 | Volume:3 | Issue:5|Papers Count:26

The sixth congress of the Iranian society of cardiac surgeons were hold at Milad tower on Oct 2009. The scientific sessions which were faced with too many special problems and difficulties, were running properly with an acceptable standard and were enough fruitful. Like any other previous ones, the second night was planned for a gala festive and was named’ a night with Rumi; with title; from Heart to the Heart.

Objectives:  Familial hypercholesterolemia is dominantly inherited disorder caused mutation by at the locus for the low-density lipoprotein receptor and is frequently associated with premature coronary artery disease. This study was performed to determine outcomes of coronary artery bypass grafting for patients with familial hypercholesterolemia.Methods: During the past 7 years, 11 from 12 patients with heterozygous familial hypercholesterolemia underwent primary coronary artery bypass grafting and 1 from 12 patients underwent PCI without hospital death. All patients received one internal thoracic artery graft and supplemental vein grafts. After operation all patients received diet therapy and intensive cholesterol-lowering therapy. 4 patients received low density lipoprotein aphaeresis. Results:  Both groups were similar regarding During follow up period (range 1 to 84 months, mean 16 months) there was no cardiac death but 2 of them had recurrent disease. Inspite of severe coronary atherosclerosis, these patients with familial hypercholesterolemia showed good short term outcomes after coronary artery bypass surgery.Conclusion: The present finding suggests that aggressive use of arterial and venous grafts, intensive cholesterol-lowering therapy and low-density lipoprotein aphaeresis may be useful in patients with familial hypercholesterolemia.

Long QT syndrome (LQTS) results from structural abnormalities in the potassium channels of the heart, which predispose affected persons to an accelerated heart rhythm (arrhythmia). Nifekalant, a new class III antiarrhythmic agent developed in US, blocks selectively a rapidly-activating component of the delayed rectifier potassium channel (IKr) in cardiac myocytes, and causes dose-dependent increase in artrial and ventricular refractory periods and repolarization. We report a case of congenital long QT syndrome (LQTS) with recurrent ventricular fibrillation inadvertently treated with intravenous nifekalant. Treatment neither modified the rate-corrected QT interval nor induced torsades de points. Subsequent genotyping of the patient revealed a missense mutation in the extracellular loop between S5 and the pore region of HERG (K595E). Since HERG encodes the IKr channel, LQT2 patient may be more tolerant of pure IKr blockers than other LQTS genotypes.

The is no ideal heart valve substitute, both mechanical and biologic heart valve have significant limitation in term of durability, growth potential (for infant and children), compatibility, resistance to infection(1).Tissue-engineered heart valve have been proposed by physicians and scientists alike to be the ultimate solution for treating valvular heart disease rather than replacing a diseased or defective native valve with a mechanical or bioprosthesis, a tissue engineered valve would be a living organ with the capability for growth, repair and remodeling in the same way that the native heart valve does.Over the last decade attempts to create tissue engineered heart valve have been made with varying degrees of success, constructing these valve from a Varity of cell types and scaffolding materials. Early results in animals and limited clinical application are promising although it will take many years to demonstrate that long-term performance of this valve is comparable or better than conventional prosthetic heart valve.

Objectives: We analyzed the role of magnesium sulfate (MgSO4) supplementation during cardiopulmonary bypass in pediatric patients undergoing cardiac surgery, assessing the incidence of hypomagnesemia and the incidence of junctional ectopic tachycardia.Methods: We performed a randomized, double-blind, controlled trial in 99 children. MgSO4 or placebo was administered during the rewarming phase of cardiopulmonary bypass: group 1, placebo group (29 patients); group 2, 25 mg/kg of MgSO4 (30 patients); and group 3, 50 mg/kg of MgSO4 (40 patients).Results: At the time of admission to the cardiac intensive care unit, groups receiving MgSO4 had significantly greater levels of ionized magnesium (group 1, 0.51±0.07; group 2, 0.57±0.09; group 3, 0.59±0.09). Hypomagnesemia before bypass was common (75%–86.2%) and not significantly different among the groups. The proportion of hypomagnesemia decreased significantly at admission to the cardiac intensive care unit in groups receiving MgSO4 (group 1, 77.8%; group 2, 63%; group 3, 47.4%). Patients receiving placebo (group 1) had a significantly greater occurrence of junctional ectopic tachycardia than groups receiving MgSO4 (group 1, n=5 [17.9%]; group 2, n=2 [6.7%]; group 3, n=0 [0%]). Age (<1 month), Aristotle score (>4), and history of cardiac failure were associated with junctional ectopic tachycardia. None of the patients with those characteristics in group 3 had junctional ectopic tachycardia. No association was found between study groups and the Pediatric Risk of Mortality score or length of stay in the cardiac intensive care unit.Conclusions: Supplementation with MgSO4 during cardiopulmonary bypass seems to reduce the incidence of hypomagnesemia and junctional ectopic tachycardia at admission to the cardiac intensive care unit. This effect seems to be dose related.

Clopidogrel (Plavix) given before the operation increases bleeding complications following coronary artery bypass grafting (CABG). High perioperative doses of aprotinin (Trasylol) are known to reduce bleeding and transfusions after cardiac surgery, but may increase the risk of thrombosis, renal impairment, and mortality. The aim of the study was to evaluate the clinical effects of aprotinin given in high doses intra- and postoperatively vs. a low postoperative dose in patients on clopidogrel. Patients admitted for first-time CABG and receiving clopidogrel with or without aspirin, were prospectively randomized either to receive a total of 75,000 kallikrein inhibitor unit (KIU)/kg aprotinin given intra- and postoperatively or 25,000 KIU/kg aprotinin after the operation. Three hundred and ninety-nine patients aged 67 years (32-87 years) were included. Postoperative bleeding was slightly different, but moderate in both groups. The transfusion rate was similar, as were the incidences of postoperative neurological disturbances and myocardial infarction. Renal impairment and need for inotropic drugs were more frequent in the high dose group. Thirty-day mortality was similar (high dose 2%, low dose 0.5%, P=0.22). A low postoperative dose of aprotinin in patients receiving clopidogrel is safe and has comparable effects regarding postoperative bleeding complications as a high dose.

Introduction: Selective antegrade cerebral perfusion is a well-described neuroprotective technique used in proximal aortic surgery. This study investigated whether selective antegrade cerebral perfusion is associated with improved outcomes in both emergency and elective settings compared with deep hypothermic circulatory arrest alone.Methods: Retrospective review was performed for all cases of proximal aortic surgery between January 2004 and May 2007. Of these 271 patients, 105 had emergency and 166 had elective operation. Selection bias was controlled using propensity scoring methods. Multivariable logistic regression analysis was used to model adverse outcomes as a function of selective antegrade cerebral perfusion, emergency status, and their interaction, adjusted for the propensity score. Adjusted odds ratios were formulated with 95% confidence intervals.Results: Operative mortality occurred in 12.1% (33/271) of patients: 8.8% (18/205) in patients with selective antegrade cerebral perfusion versus 22.7% (15/66) in those with deep hypothermic circulatory arrest alone (P=.003). Temporary neurologic dysfunction occurred in 5.9% (15/255) of patients: 4.5% (9/198) in selective antegrade cerebral perfusion versus 10.5% (6/57) in deep hypothermic circulatory arrest alone (P=.09). Stroke occurred in 4.3% (11/255) of patients with no difference between groups. In the elective setting, selective antegrade cerebral perfusion was associated with a significant decrease in operative mortality compared with deep hypothermic circulatory arrest alone. Overall, selective antegrade cerebral perfusion was associated with shorter intensive care unit and ventilator times and fewer renal and pulmonary complications. Significant multivariable predictors of operative mortality were emergency status, previous coronary surgery, and cardiopulmonary bypass time.Conclusions: Use of selective antegrade cerebral perfusion confers a survival advantage during proximal aortic surgery that is most apparent in the elective setting. Improved resource utilization and fewer pulmonary and renal complications were observed in patients with selective antegrade cerebral perfusion.

Objectives: To identify pretransplant factors associated with postprocedural right ventricular failure and the relationship between right ventricular failure and long-term survival in children.Methods: Records were reviewed for children having heart transplantation from 2000 to 2006.Results: Right ventricular failure was identified by clinical and echocardiographic parameters in 33/129 (25%) recipients: dilated cardiomyopathy in 14/90 (15%), congenital heart disease in 11/27 (41%), and restrictive cardiomyopathy in 8/12 (66%). In 9 of 12 (75%), known elevated (reactive) pulmonary vascular resistance progressed to right ventricular failure. In a further 23/117 (20%) recipients, pulmonary vascular resistance within predefined acceptable range progressed to right ventricular failure. Multiple logistic regression analyses indicated elevated pulmonary vascular resistance (odds ratio 12.30; 95% confidence interval 2.73, 55.32; P=.001) and primary diagnosis, restrictive cardiomyopathy (odds ratio 9.21; 95% confidence interval 2.07, 41.12; P=.004), and congenital heart disease (odds ratio 4.07; 95% confidence interval 1.36, 12.19; P=.012) were strongly associated with right ventricular failure, but duration of heart failure, pretransplant mechanical support, donor status, and ischemic times were not. Treatment included inhaled nitric oxide in 28 (84%), mechanical support in 10 (31%), hemofiltration in 13 (40%), and retransplantation in 2. A Cox multiple regression model including: primary diagnosis, right ventricular failure, and elevated pulmonary vascular resistance indicated that only the latter was independently linked with eventual mortality (hazards ratio 5.45; 95% confidence interval 1.36, 21.96; P=.017).Conclusions: Primary diagnosis and pretransplant elevated reactive pulmonary vascular resistance are both linked to the evolution of right ventricular failure. Pulmonary vascular resistance assessment in end-stage heart failure is challenging; therefore, avoidance of right ventricular failure may not always be possible. Aggressive early treatment may mitigate the effects of right ventricular failure: pretransplant elevated pulmonary vascular resistance was independently associated with longterm survival, but right ventricular failure was not.

Background:  The integrity of the blood-cerebrospinal fluid (CSF) barrier during cardiopulmonary bypass (CPB) with hypothermic circulatory arrest (HCA) has not been systematically studied, especially in children. We tested the hypothesis that the blood- CSF barrier is disrupted by CPB. Methods:  The study randomized 25 piglets (mean weight, 11 kg) to five groups (5 per group): anesthesia alone (control); CPB at 37°C with full-flow (FF); CPB at 25°C with very low flow (LF); and HCA at 15°C and 25°C. pH-stat strategy was applied during CPB. An epidural catheter was inserted into the cisterna magna for collection of CSF. CSF and blood samples were collected at seven points: after induction of anesthesia (baseline), at 10, 50 and 115 minutes after start of CPB, just before the end of CPB, and at 30 and 120 minutes after CPB. Albumin levels in CSF and plasma were measured to assess blood-CSF barrier integrity and the albumin ratio (CSF/plasma) was calculated (Q Alb). Results: In both HCA groups, the Q Alb was significantly higher than in the control and 37°C FF groups (all p < 0.05), whereas Q Alb in the 37°C group was not significantly different vs control.Conclusions: The blood-CSF barrier is impaired by CPB with 1 hour of 15°C or 25°C HCA. Further investigations are needed to understand the behavior of the blood-CSF barrier during CPB and its role in neuroprotection.

Background: This study was undertaken to evaluate long-term results of biventricular repairs for congenitally corrected transposition of the great arteries, and to analyze the risk factors that affect mortality and morbidity.Methods :Between 1983 and 2009, 167 patients with congenitally corrected transposition of the great arteries underwent biventricular repairs. The physiologic repairs were performed in 123 patients, and anatomic repairs in 44. Average follow-up was 9.3 ± 6.6 years.Results: Kaplan-Meier estimated survival was 83.3%±0.5% at 25 years in biventricular repair. In anatomic repair, left ventricular training and right ventricular dysfunction had negative impact on survival, but bidirectional cavopulmonary shunt had positive impact on survival. The reoperation-free ratio was 10.1%±7.8% at 22 years after physiologic repair, and 46.2%±12.4% at 15 years after anatomic repair (p=0.885). Freedom from any arrhythmia was 49.6%±7.5% at 22 years after physiologic repair, and 60.8%±14.8% at 18 years after anatomic repair (p=0.458). Freedom from systemic atrioventricular valve and ventricular dysfunction as well as tricuspid valve and right ventricular dysfunction was significantly higher in anatomic repair than in physiologic repair. Conclusions :Long-term results of biventricular repair were satisfactory. Patients presenting with right ventricular dysfunction or need for left ventricular training represent a high-risk group of anatomic repair for which selection criteria are particularly important. Late functional outcomes of anatomic repair were excellent compared with physiologic repair. Anatomic repair is the procedure of choice for those patients if both ventricles are adequate or if surgical technique is modified with the help of additional a bidirectional cavopulmonary shunt.

Objectives: We aimed to describe management strategies for neonates with hypoplastic left heart syndrome over the past 18 years in the United States and to identify determinants of institutional management decisions.Methods: Neonates with hypoplastic left heart syndrome were retrospectively identified by use of the Nationwide Inpatient Sample 1988–2005. Treatment was categorized as (1) transplantation, (2) Norwood operation (as defined by Risk Adjustment in Congenital Heart Surgery), (3) transfer to another facility, or (4) no surgical intervention (comfort care).Results: A total of 3286 neonates were identified, yielding a national estimate of 16,781 ± 586 cases. Of these, 2% (348 ±47) underwent transplantation, 16% (2767±286) had Norwood operations, 25% (4143±156) were transferred to another facility, and 57% (9523±436) had comfort care. Changes in practice patterns occurred over time, with an increasing number of neonates undergoing Norwood, concomitant with decreasing numbers undergoing transplantation (P<.001). Bias toward the Norwood operation over time paralleled a significant, nearly linear decrease in the in-hospital mortality rate for the Norwood operation, from 86% in the earliest sextile to 24% in the most recent sextile (P<.001). Prevalence of transfer to definitive care hospitals remained constant over time, as did the number of infants (approximately half) who received no surgery (comfort care.(Conclusions: Despite improved surgical outcomes, the majority of infants continue to receive no surgical care. There has been an increase in the number of infants offered the Norwood operation for hypoplastic left heart syndrome over the past 2 decades, which seems to have come mostly owing to a decrease oftransplants. The advent of prenatal diagnosis has not decreased the proportion of neonates born at institutions unequipped to provide definitive care.

Background: Stroke remains an important complication after coronary artery bypass graft surgery (CABG). We sought to determine the frequency and death-related incidence of stroke after on-pump and off-pump CABG.Methods: We analyzed 4,869 consecutive isolated CABG performed in our institution. Of these, 3,490 (71.7%) were off-pump and 1,379 (28.3%) were on-pump. Propensity matched samples of 1,379 off-pump and 1,379 on-pump were compared on clinical presentation and The Society of Thoracic Surgeons (STS) predicted scores for risk of postoperative mortality and stroke. Univariate analyses were used to compare the relationship of off-pump and on-pump groups to postoperative mortality and stroke. Multivariate logistic regression was used to determine the unique association between all variables and occurrence of mortality after stroke.Results: No differences were found for sex, diabetes mellitus, history of renal failure, prior stroke, or timing of surgery. Postoperative mortality occurred in 75 patients (2.7%) and stroke in 47 (1.7%). The off-pump patients had a lower rate of stroke (1.0% versus 2.4%; p < 0.01) compared with on-pump patients. Mortality after stroke occurred in 14 patients, with a lower rate occurring in the off-pump group (14.3% versus 36.4%; p = 0.07). Multivariate analyses controlling for the effect of preoperative risk factors and STS mortality risk demonstrated that off-pump status was independently  associated with an 84% decrease in the risk of death after stroke (adjusted odds ratio 0.157, 95% confidence interval: 0.035 to 0.711, p = 0.016).Conclusions: Off-pump CABG is associated with lower stroke rates and stroke-related mortality. It may be useful to consider off-pump CABG for patients who are at higher risk for postoperative stroke.

Background:After tetralogy of Fallot (TOF) repair, severe pulmonary insufficiency is known to impair biventricular function. Pulmonary valve replacement (PVR) alleviates symptoms, normalizes right ventricular volumes, and improves ventricular function. Most studies addressing the role of PVR have examined older adolescents or adults. Less is known about the potential benefits of PVR in preadolescents with TOF and significant right ventricular dilatation. Methods: We reviewed the clinical data for all preadolescents (13 years) with TOF who underwent cardiac magnetic resonance imaging (cMRI) or PVR, or both. Serial cMRI data were analyzed to determine the change in indexed right ventricular end-diastolic volume (RVEDV) and biventricular ventricular ejection fractions. Available cMRI data after PVR were compared with data before PVR. Results: During the study period, 101 preadolescents with TOF had cMRI. The median age of complete repair was 6 months (range, 6 days to 3.4 years). The mean RVEDV at the first study was 135 ± 39 mL/m2. For 32 with serial cMRI studies, the RVEDV increased at a mean yearly rate of 9 mL/m2. Ventricular systolic function was impaired in 46 (46%). Forty-two patients underwent PVR at a mean age of 8 ± 3 years. No hospital deaths occurred, and no pulmonary valve reinterventions have been required.Conclusions: Significant right ventricular dilatation is common in preadolescents after transannular patch repair of TOF. Routine follow-up of this population should incorporate cMRI. Further studies will be needed to determine whether a strategy of early PVR might improve intermediate-term outcome.

Background: Studies demonstrate that cardiopulmonary bypass (CPB) causes intraoperative and postoperative hyperglycemia. Hyperglycemia has been associated with morbidity and mortality after infant cardiac surgery. We studied the effects on early postoperative outcomes of glucose (GLU) changes during and after pediatric cardiac surgery.Methods: The records of 144 infants less than 10 kg who underwent CPB for a variety of congenital cardiac procedures were reviewed. The GLU values (at multiple intervals during and after surgery), age, weight, CPB time, ultrafiltration volume, and risk adjustment for congenital heart surgery (RACHS-1) score were recorded. Univariate and multivariate linear and binary logistic regression were used to examine the dependence of the composite outcome mortality or postoperative infection, the mechanical ventilation time (VENT time), and the length of stay (LOS), on these variables.Results: The RACHS-1 score was the only significant predictor of the composite variable "mortality or infection" (p=0.008). Glucose at any time was not a significant factor predicting this outcome. Lower pre-CPB GLU, younger age, and higher RACHS-1 score were significant predictors of greater LOS and VENT time.Conclusions :In this study, post-CPB and postoperative hyperglycemia were not risk factors for postoperative morbidity and mortality after infant cardiac surgery.

Objective: We sought to delineate the safety and efficacy of sequential and composite coronary artery bypass grafting (CABG) with exclusively arterial grafts to more than five coronary branches including small coronary vessels.Methods: We reviewed the clinical records of 633 consecutive patients with 2617 bypass grafts who underwent total arterial off-pump complete revascularisation for three-vessel coronary regions without aortic manipulation. Group I consisted of 263 patients with a single in situ internal thoracic artery (ITA), while group II consisted of 370 patients with bilateral in situ ITA. Subgroups I-A and I-B consisted of 242 patients with three or four distal anastomoses and 21 patients with more than five distal anastomoses, respectively. Subgroups II-A and II-B consisted of 199 patients with three or four anastomoses and 171 patients with more than five anastomoses, respectively.Results: The early mortality and morbidity rate and the angiographic graft patency in the groups I and II were similar, while the rate of antegrade flow in group II (92.4%, 1349/1460) was significantly higher than that in group I (89.4%, 638/714, p = 0.02). Intra-operative graft flow measured at the proximal portion of the in situ ITA in group II (79 ± 35 ml min–1) was significantly larger that that in group I (53 ± 31 ml min–1, p < 0.0001). The patency rate of bypass grafts to small coronary vessels (1.25 mm or less in diameter) was 97.4% (626/643). The early mortality rates in subgroups I-A and I-B were 1.2% (3/242) and 0% (0/21), respectively (p = 0.61). The graft flow and incidence of competitive flow was comparable in subgroups I-A and I-B. The early mortality rates in subgroups II-A and II-B were 0.5% (1/199) and 0.6% (1/177), respectively (p = 0.91). The graft flow to five or more coronary branches (81 ± 35 ml min–1) was significantly greater than that to three branches (67 ± 30 ml min–1, p = 0.01).Conclusions: For more than five target branches, sequential and composite arterial grafting with the ITA and a radial artery was safe and reliable, even when the target vessels were small. Bilateral in situ ITA would be feasible for the patients with multiple stenotic lesions, because of abundant bypass flow and less incidence of competitive flow. Durable completeness of revascularisation can be expected.

Objectives: We report our comparative experience of on-pump and off-pump full arterial coronary artery bypass grafting (CABG) using both internal mammary arteries (IMAs) anastomosed as a Y-graft.Methods: A single-center clinical study was conducted prospectively between January 2003 and May 2008. It compared the short- and mid-term clinical outcomes of on- and off-pump arterial revascularization where the left internal mammary artery (LIMA) was anastomosed to the left anterior descending (LAD) artery while the free right internal mammary artery (RIMA) graft taking off from the LIMA was used to bypass different coronary targets.Results: 192 patients were divided into 77 on-pump and 115 off-pump procedures based on the intention to treat. The mean age in both groups was 60.2±11.7 and 68.1±10.6 years, respectively (p<0.05). Mean predictive logistic EuroSCORE was 3.5±6.7% for the on-pump group and 7.3±8.6% for the off-pump group (p<0.0001). Mean number of distal anastomoses were 2.7±0.6 (group ON) and 2.5±0.6 (group OFF) (p=NS). Postoperative mortality was 2 patients (2.6%) in the on-pump group and 4 patients (3.4%) in the off-pump group (p=0.63). No major adverse cardiac event, no stroke and no late death were reported during the follow-up that averaged 36.5±18.6 months. Angina recurrence was 3 patients (2.6%) in off-pump and 2 patients (3.5%) in on-pump group (p=NS). Conclusions: The use of a free RIMA as Y-graft from the LIMA performed off pump eradicates aortic manipulations and provides complete revascularization to high-risk patients with mortality similar to the one of a lower risk population operated on pump. The morbidity and cost was lower in the off-pump group. This advocates for the widespread usage of the technique in high-risk patients.

Objective: Various definitions of impairment of renal function after coronary artery bypass grafting (CABG) are used in the literature. Depending on the definition, several risk factors are identified. We analysed our data to determine the risk factors for postoperative deterioration of the creatinine clearance of 10% or more.Methods: All patients undergoing isolated coronary surgery in a single centre between January 1998 and December 2007 are included. Clinical data, including demographics and renal risk factors, were prospectively collected in our database. The most recent preoperative serum creatinine level and the maximum serum creatinine level within the first week postoperatively were used to calculate the creatinine clearance. A deterioration of 10% or more was considered to be an endpoint for this study. The records of 144 infants less than 10 kg who underwent CPB for a variety of congenital cardiac procedures were reviewed. The GLU values (at multiple intervals during and after surgery), age, weight, CPB time, ultrafiltration volume, and risk adjustment for congenital heart surgery (RACHS-1) score were recorded. Univariate and multivariate linear and binary logistic regression were used to examine the dependence of the composite outcome mortality or postoperative infection, the mechanical ventilation time (VENT time), and the length of stay (LOS), on these variables.Results: In 10 098 out of a total of 10 626 patients, the preoperative as well as the postoperative creatinine clearance could be calculated. In 1053 patients, the deterioration of the creatinine clearance was 10% or more. We could identify the following risk factors: advanced age, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, emergency operation, previous cardiac surgery, low preoperative haemoglobin level, high preoperative C-reactive protein level, perioperative myocardial infarction, re-exploration and the number of blood transfusions.Conclusions: Risk factors for the deterioration of renal function after revascularisation have been confirmed in this study. In addition, we found peripheral vascular disease, previous cardiac surgery, low preoperative haemoglobin, increased preoperative C-reactive protein level, perioperative myocardial infarction and the number of blood transfusions to be risk factors that have not been described earlier.

With the general increase in human lifespan, cardiac surgeons are faced with treating an increasing number of elderly patients. The aim of our study was to investigate whether advanced age poses an increased risk for major morbidity and mortality with repair of acute type A aortic dissection. Between 2000 and 2008, 119 patients underwent emergency operation for acute type A aortic dissection at two institutions; 90 were younger than 70 years of age and 29 patients were 70 years or older. Major morbidity, operative and 5-year actuarial survival were compared between groups. The operative mortality rates were comparable between the two groups (18.9% in patients <70 years vs. 24.1% for patients 70 years, P=0.6). There was no difference in the rates of reoperation for bleeding (<70 years 31.7% vs. 14.3% for 70 years, P=0.09), stroke (18.9% for those <70 years vs. 20.7% for those 70 years, P=0.79), acute renal failure (22.2% for those <70 years vs. 17.2% for those 70 years, P=0.79) or prolonged ventilation (34.4% for those <70 years vs. 24.1% for those 70 years, P=0.36) between the two groups. Actuarial 5-year survival rates were 77% for patients <70 years vs. 59% for patients 70 years (P=0.07). The mortality for patients who presented with hemodynamic instability was markedly higher (10 out of 14 patients, 71.4%) compared with the mortality of those who presented with stable hemodynamics (21 out of 88 patients, 23.9%, P<0.001), regardless of age group. No significant differences in operative mortality, major morbidity and actuarial 5-year survival were observed between patients 70 years and younger patients although there was a trend toward a lower actuarial 5-year survival in older patients. Surgery for type A acute aortic dissection in patients 70 years or older can be performed with acceptable outcomes. Hemodynamic instability portends a poor prognosis, regardless of age.

Background: The increasing use of biologic conduits and the advances in reparative aortic root procedures has increased the number of patients who may require reoperation on the aortic root. Although the primary operation yields excellent results with a low risk for morbidity and mortality, reoperation on the aortic root is still challenging.Methods: We reviewed retrospectively our experience in 46 patients (38 men; mean age, 57±11 years) who underwent aortic root reoperations in the last 7 years. Of these, 42 had received prior aortic root replacement. The indications for reoperation included prosthesis infection in 16, false aneurysm in 16, and degenerative or postdissection aneurysm and valve prosthesis failure. Aortic root re-replacement was performed in 39 patients (85%) and closure of false aneurysm in 7. Univariate and multivariate analysis on 22 perioperative variables were performed.Results: In-hospital mortality was 6.5% (3 patients). The postoperative course was complicated in 19 (41%). At multivariate analysis, perioperative myocardial infarction was a risk factor for hospital mortality (2 patients). Survival was 88% at 1 year and 74% at 5 years. No differences were found in survival according to redo indication. Freedom from reoperation on the aortic root was 100% at 1 year and 90% at 5 years.Conclusions: Reoperation on the aortic root can be performed with acceptable mortality and good midterm and long-term outcome; however, the postoperative complication rate is still high.

Background: Although adenosine (ADO) has been shown to have beneficial effects against tissue injury after myocardial ischaemia, the controversy still remains regarding the optimal timing, dose, temperature, method of ADO administration and duration of exposure to the drug. This study investigates the cardioprotective effect of exogenous ADO pretreatment as an adjunct to 1 mmol l–1 ADO cold (12 °C) blood cardioplegia during heart valve replacement surgery.Materials and methods: Thirty patients with rheumatic heart valve disease undergoing heart valve replacement operations were randomly assigned to two groups: group C (n = 15) and group A (n = 15). Patients in group C were the control group and received antegrade cold (12 °C) high-potassium ([K+] = 20 mol l–1) institute blood cardioplegia. The patients in group A received 10-min 100 μg kg–1 min–1 ADO pretreatment before application of the aortic cross-clamp and antegrade 1 mmol l–1 adenosine high-potassium ([K+] = 20 mol l–1) cold (12 °C) blood cardioplegia. Clinical outcomes were observed before, during and after the operation. Plasma level markers of myocardial damage: cardiac Troponin I (cTnI), creatine kinase (CK-MB) and inflammatory factors (interleukin (IL)-6 and IL-8) were obtained from serial venous blood samples after induction, 5 min after cross-clamp of aorta, 10 min after clamp-off, 1 h after return to ICU and postoperatively 24 h and 48 h. Right atrial samples were harvested before cross-clamp and after clamp-off.Results: Heart valve replacement was successful in all patients. There were no differences regarding operative parameters in the two groups. Time to arrest (during cardiolegia perfusion electrocardiography (ECG) change to a line) was shorter in group A compared to group C (19.9 ± 4.6 s vs 29.3 ± 10.6 s; p=0.03). Group A also had lower cTnI and IL-8 levels (p=0.03) at 10 min after aortic declamping, and lower IL-6 (p=0.04) at 24 h postoperatively as well. Ultrastructural changes were slighter in group A than group C after clamp-off. Compared to group C, post-reperfusion biopsies in group A displayed only slight overall ultrastructural changes, and scored significantly better on mitochondrial damage (group A 2.23±0.65 vs group C 2.85±0.66) (p=0.04).Conclusion: Compared with simple cold blood cardioplegia in heart valve replacement patients, ADO pretreatment as an adjunct to 1 mmol l–1 ADO cold blood cardioplegia may reduce cTnI, IL-6 and IL-8 release, resulting in reduced myocardial injury in ultrastructure after surgery.

Background: Data suggest that patient-prosthesis mismatch (PPM) adversely effects late survival after aortic valve replacement (AVR). This study examined the incidence and implications of PPM in patients undergoing isolated AVR.Methods: Prospectively collected data on patients undergoing isolated AVR for aortic stenosis between January 1, 1997 and December 31, 2007 were analyzed. The projected effective valve orifice area from in vivo data was indexed to body surface area (EOAi). PPM was defined as moderate for EOAi of 0.85 cm2/m2 and severe if 0.6 cm2/m2. The reference group comprised patients with EOAi > 0.85 cm2/m2. The effect of PPM on postoperative survival was assessed by multivariate analysis. Results: Of 801 patients, PPM was severe in 48 (6.0%), moderate in 462 (57.8%), and nonexistent in 291 (36.4%). Mismatch was associated with increasing age and female gender, thus resulting in an increase in the EuroSCORE (reference group, 4.9±2.6; moderate PPM, 5.8±2.4; and severe PPM, 6.1±2.1; p<0.001). PPM did not significantly increase hospital mortality. Four deaths occurred in the reference group (1.4%), 12 in the moderate PPM (2.6%), and none in the severe PPM group (p=0.311). The 5-year survival estimates were 83% in reference, 86% in moderate PPM, and 89% in severe PPM (p = 0.25). By multivariate analysis, PPM was not an independent risk factor for reduced in-hospital or late survival.Conclusions: Moderate PPM is common in patients undergoing AVR for aortic stenosis, but severe mismatch is rare. Patients with PPM have similar early and late postoperative survival rate.

Objective: To determine the long-term outcomes of mitral valvuloplasty for myxomatous valve disease, rheumatic valve disease, and functional mitral regurgitation. Methods: A total of 1503 patients underwent mitral valvuloplasty by a single surgeon between February 1972 and April 2008 and were retrospectively reviewed for short- and long-term results. Overall mean age was 60.3 ± 13.7 years, and 57% were male. The cause was rheumatic in 193 patients, myxomatous in 1042 patients, and ischemic and nonischemic functional mitral regurgitation in 236 patients. Ring annuloplasty was performed in 1306 patients (87%). Commissurotomy was the primary repair for rheumatic valves, posterior leaflet resection and reconstruction was the most common repair for myxomatous valves (527/1042 [51%]), and ring reduction annuloplasty was the primary operation for functional mitral regurgitation.Results: The 30-day mortality was 19 of 1503 patients (1.3%) and significantly higher in the functional mitral regurgitation group (11/236 patients, 4.7% vs 0.5% in the rheumatic group and 0.6% in the myxomatous group, P < .01). The 10-, 20-, and 30-year survivals were similar for the rheumatic and myxomatous groups (77%, 56%, and 39% vs 79%, 62%, and 52%, respectively) but significantly less for the functional mitral regurgitation group (44%, 4%, and 0%, respectively, log-rank P<.0001). The 10- and 20-year freedom from reoperation rates were significantly better for the myxomatous group than for the rheumatic group (90% and 82% vs 66% and 34%, log-rank P<.0001), with a 30-year freedom from reoperation of only 10% for rheumatic repair. In the myxomatous group, freedom from reoperation was lower in patients with anterior leaflet pathology (P=.0008).Conclusion: Follow-up data to 36 years demonstrate that cause strongly determines survival and durability of mitral valvuloplasty; patients with rheumatic valve disease who survive more than 20 years require reoperation, whereas functional mitral regurgitation carries the highest short- and long-term mortality rates and lowest freedom from reoperation. Mitral valvuloplasty for myxomatous valves demonstrates the longest durability, with many patients free from reoperation at 30 years.

Objective: Aortic valve replacement for aortic regurgitation (AR) has been established as a standard treatment but implies prosthesis-related complications. Aortic valve repair is an alternative approach, but its mid- to long-term results still need to be defined.Methods: Over a 12-year period, 640 patients underwent aortic valve repair for regurgitation of a unicuspid (n=21), bicuspid (n=205), tricuspid (n=411) or quadricuspid (n=3) aortic valve. The mechanism of regurgitation involved prolapse (n=469) or retraction (n=20) of the cusps, and dilatation of the root (n=323) or combined pathologies. Treatment consisted of cusp repair (n = 529), root repair (n=323) or a combination of both (n = 208). The patients were followed clinically and echocardiographically; follow-up was complete in 98.5% (cumulative follow-up: 3035 patient years). Results: Hospital mortality was 3.4% in the total patient cohort and 0.8% for isolated aortic valve repair. The incidences of thrombo-embolism (0.2% per patient per year) and endocarditis (0.16%per patient per year) were low. Freedom from re-operation at 5 and 10 years was 88% and 81% in bicuspid and 97% and 93% in tricuspid aortic valves (p=0.0013). At re-operation, 13 out of 36 valves could be re-repaired. Freedom from valve replacement was 95% and 90% in bicuspid and 97% and 94% in tricuspid aortic valves (p=0.36). Freedom from all valve-related complications at 10 years was 88%.Conclusions: Reconstructive surgery of the aortic valve is feasible with low mortality in many individuals with aortic regurgitation. Freedom from valve-related complications after valve repair seems superior compared to available data on standard aortic valve replacement.

Surgical revascularization for coronary artery lesions secondary to Kawasaki disease (KD) has been rarely reported in adolescent patients. We reported a young adult case with no coronary risk factors but with a giant solitary coronary aneurysm and obstructive thrombosis inside presumably secondary to KD who underwent coronary artery bypass grafting (CABG) with left internal thoracic artery (LITA) and SVG.Because coronary artery sequelae of KD can be a cause of ischemic heart disease even in young adults, heightened awareness of this possibility is required for young adults with coronary lesions but without coronary risk factors.Kawasaki disease is an acute febrile illness affecting mainly infants and children. The fatal complication of Kawasaki disease is coronary involvement pertaining to coronary artery aneurysms. Surgical experience of adults that had childhood Kawasaki disease with coronary lesion has been rarely reported (1). We experienced coronary artery bypass grafting in a 16 years old young man with no risk factors for atherosclerosis but with coronary lesions possibly secondary to Kawasaki disease.

Fryns syndrome is characterized by multiple congenital anomalies including congenital diaphragmatic hernia (CDH), and congenital heart disease (CHD). The prognosis of infant with Fryns syndrome and left sided CDH when associated with pulmonary hypoplasia is grave. We report a 2- year old boy with Fryns syndrome who had right sided CDH, Tetralogy of Fallot, and other multiple congenital anomalies. The patient survived a successful operation of both heart and diaphragmatic defects.

A 20y old, woman in week 34 of her first pregnancy attended her local hospital because of chest pain and dyspnea, and in her echocardiography VSD was reported. But, because of begining her labor pain and uterin contraction her infant was born through vaginal delivery.In 3rd day after delivery she came to Rajaee Hospital because of increase in heart rate, and tachypnea. Subsequently a dry cough, dyspnea and orthopnea had developed. Examination showed tachycardia with 120 beats / min .Blood pressure was 120/60 and on auscultation a continuous mid systolic murmur was heard at the left sternal border. The CXR showed increased vascular marking and ECG was normal.In view of the possibility of pulmonary emboli, it was felt that CT.angiographic confirmation of the diagnosis should be obtained. There is no sign of PTE inCT. angiography.