Biomedical subjects

Eugene H Blackstone

Publications and source records attributed to Eugene H Blackstone.

At least 19 recordsLinked to original sources

PubMed2006

Can pulmonary conduit dysfunction and failure be reduced in infants and children less than age 2 years at initial implantation?

OBJECTIVES: We sought to examine risk factors for pulmonary conduit failure or dysfunction in infants less than age 2 years at initial implantation. METHODS: From 2002 to 2005, 241 children at 17 institutions were discharged alive after initial pulmonary conduit insertion. Initial conduit type was pulmonary allograft in 37%, aortic allograft in 29%, bovine jugular venous valved conduit in 25%, porcine heterograft in 2%, and decellularized allograft in 7%. Parametric hazard analysis determined time-related prevalence and associated risk factors for pulmonary conduit intervention and explantation. Serial echocardiographic measurements after conduit implant were analyzed by mixed regression models. RESULTS: There were 89 first conduit-related interventions after discharge and 37 initial conduit explants were performed. First conduit intervention occurred at a constant rate, with a prevalence of 58% at 3 years from initial implant. Pulmonary conduit explantation (30% at 3 years) was characterized by an early-rising risk, suggesting that catheter-based intervention effectively blunts this early initial risk. Common risk-factors for first conduit intervention and explantation were smaller conduit Z-score and younger age at initial conduit implant, and the presence of pulmonary arborization abnormalities or stenoses. Pulmonary conduit peak gradient and regurgitation progressed nonlinearly in all patients over time. Gradient progressed more rapidly in children with aortic allografts and when initial conduit Z-score was less than +1 or more than +3. Pulmonary conduit regurgitation also progressed more rapidly in children with initial conduit Z-score greater than +3 and in those without jugular venous valved conduits, especially aortic allografts. CONCLUSIONS: Pulmonary conduit durability and hemodynamic function in patients undergoing initial conduit insertion at less than age 2 years can be improved by using pulmonary conduits with Z-scores between +1 and +3.

Blood Vessel Prosthesis↗

PubMed2006

Occurrence and risk factors for reintervention after coronary artery bypass grafting.

BACKGROUND: Reintervention after coronary artery bypass grafting (CABG) is common. We sought to determine its occurrence and identify patient characteristics and operative techniques that influence the need or bias for reintervention. METHODS AND RESULTS: From 1971 to 1998, 48,758 patients underwent primary isolated CABG, and 1000 patients per year were actively followed-up every 5 years (n =26,927). A multivariable time-related analysis was performed to model freedom from first coronary reintervention (either reoperation or percutaneous coronary intervention) and identify patient and operative characteristics associated with first reintervention. A total of 3997 patients underwent coronary reintervention, percutaneous in 1638 and reoperation in 2359. Freedom from reintervention was 99%, 96%, 88%, 73%, 60%, and 46% at 1, 5, 10, 15, 20, and 25 years, respectively. Risk of reintervention (hazard function) demonstrated a short, rapidly declining early phase followed by a longer, slow-rising late phase. Patient variables increasing the likelihood of coronary reintervention included younger age (P<0.0001), higher triglycerides (P=0.002), lower high-density lipoprotein (P=0.006), diabetes mellitus (P<0.0001), and more extensive coronary artery disease (P=0.0005). Increasing extent of arterial grafting performed at primary operation decreased the likelihood of coronary reintervention (P<0.0001). CONCLUSIONS: Reintervention after primary CABG is common. Risk factors for arteriosclerosis and type of bypass conduit influence the need or bias for repeat coronary therapy. Aggressive post-CABG risk factor reduction and extensive arterial grafting at primary operation should decrease coronary reinterventions.

Age Factors↗

PubMed2006

Thinking beyond the risk factors.

For each risk factor for Black Death he discovered, John Graunt in 1662 made a recommendation for action, such as fleeing the night air brought to the City of London docks on foreign ships. These stopped the plague for 200 years! In this honored guest lecture, I focus on thinking beyond the risk factors to their neutralization by effective action without waiting for perfect knowledge of mechanisms. For example, the decreasing risk of repairing atrioventricular septal defect resulted from risk factors that stimulated focused research to devise a better operation. General reduction in risk reduced mortality of aortic valve replacement in patients with chronic aortic regurgitation and severe left ventricular dysfunction. Optimal timing of surgery after stabilizing patients reduced risk of the Norwood procedure. Managing intractable cardiogenic shock reduced risk-adjusted mortality in post-infarct ventricular septal defect. However, we must think beyond traditional risk factors to neutralization of those brought by patient characteristics, imponderables, treatment delivery systems, institutions delivering care to groups of patients, and society caring for its population. There are limitations to thinking beyond risk factors. First, neutralizing strategies require improving processes or introducing new ones. Yet there may be process-outcome disconnect, or even counterintuitive or contradictory relations among outcomes and what are thought to be best processes. Nevertheless, thinking beyond risk factors to their neutralization by research, innovation, and application of knowledge can be as spectacularly successful as was fleeing foul air in halting Black Death.

Cardiac Surgical Procedures↗

PubMed2006

Gender differences in outcomes after hospital discharge from coronary artery bypass grafting.

BACKGROUND: There are few comparative data regarding long-term nonfatal outcomes for women versus men after coronary artery bypass grafting (CABG). This study compares gender differences in cardiac events in a population of hospital survivors up to 11 years after isolated CABG surgery in Ontario, Canada. METHODS AND RESULTS: A population-based cohort study (n=68,774 patients, 15,043 women) between September 1, 1991, and April 1, 2002, was assembled with linked clinical and administrative databases. Cox modeling and propensity score matching were used to compare death, cardiac readmission (angina, heart failure, myocardial infarction), repeat revascularization (angioplasty or CABG), and stroke readmission between men and women. Women were older (65+/-17 versus 62+/-13 years), more likely to present with urgent or emergent status (64% versus 56%), and less likely to receive arterial grafts (70% versus 78%). Women had a higher rate of cardiac readmission in the first year after surgery (hazard ratio [HR] of 1.5, 95% confidence interval [CI] 1.36 to 1.56), and this increased risk persisted after 1 year (HR 1.2, 95% CI 1.14 to 1.31). This was primarily due to readmissions for unstable angina (HR 1.3, 95% CI 1.24 to 1.38) and congestive heart failure (HR 1.1, 95% CI 1.06 to 1.21). Propensity-matched women had similar rates of death (HR 0.9, 95% CI 0.83 to 0.98) and repeat revascularization (HR 1.0, 95% CI 0.91 to 1.06). CONCLUSIONS: Women have a more complex clinical preoperative presentation and are more likely to be readmitted with unstable angina and congestive heart failure after CABG but experience survival similar to those seen in men. Gender differences in outcomes may be improved through durable revascularization strategies and close postoperative follow-up care targeted to women.

Aged↗

PubMed2006

Myocardial viability testing and the effect of early intervention in patients with advanced left ventricular systolic dysfunction.

BACKGROUND: The clinical value of revascularization and other procedures in patients with severe systolic heart failure is unclear. It has been suggested that assessing ischemia and viability by positron emission tomography (PET) with fluorodeoxyglucose (FDG) imaging may identify patients for whom revascularization may lead to improved survival. We performed a propensity analysis to determine whether there might be a survival advantage from revascularization. METHODS AND RESULTS: We analyzed the survival of 765 consecutive patients (age 64+/-11 years, 80% men) with advanced left ventricular systolic dysfunction (ejection fraction < or =35%) and without significant valvular heart disease who underwent PET/FDG study at the Cleveland Clinic between 1997 and 2002. Early intervention was defined as any cardiac intervention (surgical or percutaneous) within the first 6 months of the PET/FDG study. In the entire cohort, 230 patients (30%) underwent early intervention (188 [25%] had open heart surgery, most commonly coronary artery bypass grafting, and 42 [5%] had percutaneous revascularization); 535 (70%) were treated medically. Using 39 demographic, clinical and PET/FDG variables, we were able to propensity-match 153 of the 230 patients with 153 patients who did not undergo early intervention. Among the propensity-matched group, there were 84 deaths during a median of 3 years follow-up. Early intervention was associated with a markedly lower risk of death (3-year mortality rate of 15% versus 35%, propensity adjusted hazard ratio 0.52, 95% CI 0.33 to 0.81, P=0.0004). CONCLUSIONS: Among systolic heart failure patients referred for PET/FDG, early intervention may be associated with improved survival irrespective of the degree of viability.

Aged↗

PubMed2006

Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation?

BACKGROUND: It is unknown whether pulmonary vein isolation or a complete Cox-Maze procedure is needed to ablate paroxysmal atrial fibrillation in patients with mitral valve disease. Our objective was to assess the impact of different surgical treatments for this arrhythmia in patients undergoing mitral valve surgery. METHODS: From July 1993 to January 2004, 152 patients underwent combined surgical treatment of paroxysmal atrial fibrillation and mitral valve disease. Ablation procedures included pulmonary vein isolation alone (n = 31, 20%), pulmonary vein isolation with left atrial connecting lesions (n = 80, 53%), and Cox-Maze (n = 41, 27%). The latter had longer durations of atrial fibrillation than the former (p < 0.0001). Rhythm documented on 1,225 postoperative electrocardiograms was used to estimate prevalence of, and risk factors for, atrial fibrillation across time. Ablation failure was defined as occurrence of atrial fibrillation any time beyond 6 months after operation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at 22% at 2 weeks and declined to 9% at 1 year. Risk factors included older age (p = 0.09), larger left atrium (p = 0.05), and rheumatic (p = 0.003) and degenerative etiologies (p = 0.03). Freedom from ablation failure was 84% at one year. Ablation procedure did not affect prevalence of atrial fibrillation or incidence of ablation failure. CONCLUSIONS: Pulmonary vein isolation alone may be adequate treatment for patients with paroxysmal atrial fibrillation undergoing mitral valve surgery, particularly when it is of short duration. A randomized trial is necessary to examine this strategy, especially in patients with longer duration of paroxysmal atrial fibrillation.

Aged↗

PubMed2006

Truncus arteriosus associated with interrupted aortic arch in 50 neonates: a Congenital Heart Surgeons Society study.

BACKGROUND: Patients with both interrupted aortic arch (IAA) and truncus arteriosus (TA) have worse outcomes than those with either lesion in isolation. We determined outcomes and associated factors in this rare group. METHODS: From 1987 to 1997, 50 (11%) of 472 neonates with IAA were identified with TA. Site of aortic arch interruption was distal to the left subclavian artery in 16% and between the left common carotid and subclavian artery in 84%. From the common arterial trunk, the pulmonary arteries arose from a main pulmonary trunk in 46%, common orifice in 22%, and separate orifices in 32%. At presentation, truncal valve stenosis was present in 12% and regurgitation in 22%. RESULTS: There were 34 deaths, with a single early hazard phase. Overall survival from admission was 44%, 39%, and 31% at 6 months, 1 year, and 10 years, respectively. One patient had primary cardiac transplantation and 4 died without any intervention. The IAA repair alone was performed in 7 patients, with single stage repair of both IAA and TA in 38 patients. Associated factors for overall time-related death include female gender (p < 0.001), type III TA (p < 0.001) and one institution (low-risk; p < 0.001). Results improved somewhat over time (p < 0.001). At 5 years after IAA repair only 28% were alive without arch repair intervention, and at 5 years after TA repair only 18% were alive without conduit reoperation. CONCLUSIONS: The combination of IAA and TA carries high early mortality, with high risk of reinterventions in survivors. One stage repair of both TA and IAA is the optimal management.

Abnormalities, Multiple↗

PubMed2006

Persistent effect of red cell transfusion on health-related quality of life after cardiac surgery.

BACKGROUND: Although red blood cell transfusion has been associated with an increase in early morbid outcomes and reduced long-term survival after cardiac surgery, its relationship to functional quality of life after surgery has not been previously explored. Our objective was to investigate the relationship between perioperative red blood cell and component transfusion and functional health-related quality of life 6 to 12 months after cardiac surgery. METHODS: Of 12,536 patients undergoing cardiac surgical procedures between May 1995 and January 1999, 7,321 completed a self-administered Duke Activity Status Index (DASI) survey preoperatively and least one follow-up survey at nominally 6 or 12 months postoperatively. The influence of baseline DASI, preoperative risk factors, clinical status, laboratory values, operative events, and postoperative morbidities on follow-up DASI were examined with ordinal regression modeling. RESULTS: After adjustment for preoperative DASI, demographic, cardiac and noncardiac comorbidity, type of surgery, postoperative complications, and interval between follow-up DASI, during which patients continued to improve (p < 0.0001), postoperative functional status after cardiac surgery was incrementally worse the more perioperative red cells (p < 0.0001) and platelets (p = 0.02) that had been transfused. CONCLUSIONS: Red blood cell and platelet transfusion have an unintended persistently negative risk-adjusted effect on health-related quality of life after cardiac surgery that extends well beyond initial hospitalization. Reductions in functional recovery paralleled increasing units of red blood cells transfused.

Activities of Daily Living↗

PubMed2006

Mitral valve surgery in the adult Marfan syndrome patient.

BACKGROUND: Because mitral valve dysfunction in adults with Marfan syndrome is poorly characterized, this study compares mitral valve pathophysiology and morphology with that of myxomatous mitral disease, documents types of mitral valve operations, and assesses long-term survival and durability of mitral valve surgery in Marfan patients. METHODS: From May 1975 to June 2000, 27 adults with Marfan syndrome underwent mitral valve surgery. Their valve pathophysiology and morphology was compared with that of 119 patients with myxomatous mitral disease undergoing surgery from September 1995 to March 1999. Survival and repair durability were assessed at follow-up. RESULTS: Compared with myxomatous disease patients, Marfan patients had less posterior leaflet prolapse (44% versus 70%, p = 0.01), more bileaflet (44% versus 28%, p = 0.09) and anterior leaflet prolapse (11% versus 3%, p = 0.07), and presented earlier for surgery (age 41 +/- 12 years versus 57 +/- 13, p < 0.0001). Marfan patients had longer and thinner leaflets. Mitral valve repair was performed less frequently in Marfan (16 of 27, 59%) than myxomatous disease patients (112 of 119, 94%). There were no hospital deaths; at 10 years, survival was 80% and freedom from reoperation 96%, with only 1 reoperation among the 16 repairs. CONCLUSIONS: Mitral valve pathophysiology and morphology differ between Marfan and myxomatous mitral valve diseases. Valve repair in Marfan patients is durable and gives acceptable long-term results, even in adults who present with advanced mitral valve pathology. With increasing use of the modified David reimplantation operation and sparing of the aortic valve, mitral valve repair is a greater imperative, particularly since we have not had to reoperate on any Marfan patients with reimplantations.

Adult↗

PubMed2006

Transfusion in coronary artery bypass grafting is associated with reduced long-term survival.

BACKGROUND: Perioperative red blood cell (PRBC) transfusion has been associated with early risk for morbid outcomes, but risk related to long-term survival has not been thoroughly explored. Therefore, we examined the influence of PRBC transfusion and component therapy on long-term survival after isolated coronary artery bypass grafting after controlling for the effect of demographics, comorbidities, operative factors, and the early hazard for death. METHODS: The US Social Security Death Index was used to ascertain survival status for 10,289 patients who underwent isolated coronary artery bypass grafting from January 1, 1995 through June 28, 2002. The outcome measure was all-cause mortality during the follow-up period. Unadjusted survival estimates were performed using the Kaplan-Meier techniques. Survival curves for transfusion status were compared with the log-rank test. The parametric decomposition model was used for risk-adjusted survival. A balancing score was calculated for each patient and forced into the final model. RESULTS: Survival among transfused patients was significantly reduced as compared with nontransfused patients. The instantaneous risk of death displayed a biphasic pattern: a declining hazard phase from the time of the operation (early hazard) up until 6 months postoperatively and then a late hazard that continued out until about 10 years. Transfusion of red cells was associated with a risk-adjusted reduction in survival for both the early (0.34 +/- 0.02, p < 0.0001) and late phases (0.074 +/- 0.016, p < 0.0001). CONCLUSIONS: Perioperative PRBC transfusion is associated with adverse long-term sequela in isolated CABG. Attention should be directed toward blood conservation methods and a more judicious use of PRBC.

Age Factors↗

PubMed2006

Surgery for permanent atrial fibrillation: impact of patient factors and lesion set.

BACKGROUND: Whether a complete Cox-maze procedure is needed to ablate permanent atrial fibrillation in patients undergoing concomitant cardiac surgery is unknown. Our objective was to assess the effectiveness of different lesion sets in such patients. METHODS: From November 1991 to January 2004, 575 patients underwent surgical treatment of permanent atrial fibrillation (duration > 6 months); mitral valve disease was the primary indication for surgery in 74%. Procedures included pulmonary vein isolation alone (n = 68, 12%), pulmonary vein isolation with left atrial connecting lesions (n = 265, 46%), and Cox-maze (n = 242, 42%). Rhythm documented on 5,120 postoperative electrocardiograms was used to estimate time-related prevalence of, and risk factors for, atrial fibrillation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at 46% two weeks after operation, declining to 24% at one year. Patient-related risk factors for increased prevalence included older age (p < 0.0001), larger left atrium (p < 0.0001), and longer duration of preoperative atrial fibrillation (p = 0.0008). The Cox-maze procedure and lesion sets resembling it created with alternative energy sources had a similarly low prevalence of late postoperative atrial fibrillation; in contrast, pulmonary vein isolation and lesion sets that did not include a lesion to the mitral anulus were less effective. CONCLUSIONS: This study suggests that in cardiac surgical patients with permanent atrial fibrillation the left atrial lesion set should include wide pulmonary vein isolation, at least one connection between right and left pulmonary veins, and a connection to the mitral anulus. Availability of alternative energy sources to create lesions sets has virtually eliminated the need for the cut-and-sew Cox-maze procedure.

Adult↗

PubMed2006

Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial.

BACKGROUND: Although staple line buttressing is advocated to reduce air leak after lung volume reduction surgery (LVRS), its effectiveness is unknown. We sought to identify risk factors for air leak and its duration and to estimate its medical consequences for selecting optimal perioperative technique(s), such as buttressing technique, to preempt or treat post-LVRS air leak. METHODS: Detailed air leak data were available for 552 of 580 patients receiving bilateral stapled LVRS in the National Emphysema Treatment Trial. Risk factors for prevalence and duration of air leak were identified by logistic and hazard function analyses. Medical consequences were estimated in propensity-matched pairs with and without air leak. RESULTS: Within 30 days of LVRS, 90% of patients developed air leak (median duration = 7 days). Its occurrence was more common and duration prolonged in patients with lower diffusing capacity (p = 0.06), upper lobe disease (p = 0.04), and important pleural adhesions (p = 0.007). Duration was also protracted in Caucasians (p < 0.0001), patients using inhaled steroids (p = 0.004), and those with lower 1-second forced expiratory volume (p = 0.0003). Surgical approach, buttressing, stapler brand, and intraoperative adjunctive procedures were not associated with fewer or less prolonged air leaks (p >/= 0.2). Postoperative complications occurred more often in matched patients experiencing air leak (57% vs 30%, p = 0.0004), and postoperative stay was longer (11.8 +/- 6.5 days vs 7.6 +/- 4.4 days, p = 0.0005). CONCLUSIONS: Air leak accompanies LVRS in 90% of patients, is often prolonged, and is associated with a more complicated and protracted hospital course. Its occurrence and duration are associated with characteristics of patients and their disease, not with a specific surgical technique.

Administration, Inhalation↗

PubMed2006

Red cell transfusion is associated with an increased risk for postoperative atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a common complication after cardiac surgery and is associated with increased resource utilization. Recent evidence supports a role of inflammation in the development of AF. It is also known that red blood cell transfusion modulates inflammation by increasing plasma levels of inflammatory markers. Therefore, we tested the hypothesis that red blood cell transfusion increases the risk of postoperative AF for patients undergoing cardiac surgery. METHODS: Between February 2002 and January 2005, 5,841 patients underwent isolated coronary artery bypass grafting with or without valve replacement. Patient and procedural variables associated with development of new-onset AF were identified by logistic regression. Propensity score matching was used to confirm results. RESULTS: In addition to older age, prior history of AF, higher preoperative hematocrit, beta-blocker withdrawal, longer aortic clamp time, valve surgery, and intensive care unit inotropic usage, intensive care unit red blood cell transfusion increased risk for AF (odds ratio per unit transfused, 1.18; 95% confidence limits, 1.14, 1.23; p < 0.0001). For the 1,360 propensity-matched pairs, intensive care unit red blood cell transfusion was associated with a significant increase in new-onset AF (620 [46%] versus 522 [38%]; p < 0.001). CONCLUSIONS: Intensive care unit red blood cell transfusion is associated with increased occurrence of postoperative AF after cardiac surgery. This factor should be considered in identifying patients who might benefit from prophylaxis to prevent this common postoperative complication.

Aged↗

PubMed2006

Brain metastases from esophageal cancer: a phenomenon of adjuvant therapy?

BACKGROUND: Brain metastases from esophageal cancers are uncommon, yet our impression was that they occurred more frequently than expected after esophagectomy plus adjuvant therapy. Therefore, we determined (1) incidence and prevalence of, risk factors for, and survival after development of brain metastases following esophagectomy for esophageal cancer, and (2) their association with adjuvant therapy. METHODS: From 1985 to 2002, 403 patients (52%) underwent esophagectomy alone and 369 esophagectomy plus adjuvant therapy (118 [15%] preoperative only, 124 [16%] postoperative only, and 127 [16%] both). Hazard-function methodology was used to characterize time-related occurrence of brain metastases and risk factors. Inferences were confirmed by propensity analysis. RESULTS: Twenty-nine patients developed brain metastases, 20 within 1 year; 6 had undergone surgery alone, and 23 had adjuvant therapy. Prevalence was 2.5% 5 years after surgery alone, but 8.4%, 7.0%, and 18.4% after preoperative adjuvant therapy only, postoperative adjuvant therapy only, and both, respectively (p < 0.0001). Greater number of locoregional lymph node metastases was associated with brain metastases after surgery alone (p = 0.04). Distant metastases (p = 0.03) and both preoperative and postoperative adjuvant therapy (p = 0.004) were risk factors. Median survival after diagnosis of brain metastases was 3.5 months. Postesophagectomy propensity-matched survival was shorter after adjuvant therapy than after surgery alone; thus, time available for developing brain metastases after surgery alone was slightly lower. CONCLUSIONS: A dose-related increased incidence of brain metastases after adjuvant therapy for esophageal cancer cannot be explained by increased longevity. Adjuvant therapy itself, not just advanced disease, appears to create conditions conducive to developing these rapidly fatal metastases.

Adenocarcinoma↗

PubMed2006

Folding valvuloplasty without leaflet resection: simplified method for mitral valve repair.

Standard repair techniques can prove challenging in patients with severe myxomatous mitral valve disease when there is a broad-based mid-portion of the posterior leaflet and small medial and lateral scallops. We describe a new surgical technique in which the mitral valve repair was accomplished by simple folding the prolapsed segment of the posterior leaflet and by insertion of the flexible annuloplasty ring.

Adult↗

PubMed2006

Surgical management of aortopulmonary window associated with interrupted aortic arch: a Congenital Heart Surgeons Society study.

OBJECTIVE: The objective was to determine outcomes and risk factors of surgical management of patients with aortopulmonary window associated with interrupted aortic arch. METHODS: From 1987 to 1997, 472 neonates with interrupted aortic arch were enrolled prospectively from 33 institutions. Associated aortopulmonary window was present in 20 patients. Competing risk methodology determined the prevalence of reintervention for postrepair pulmonary artery and aortic arch obstruction. RESULTS: Interrupted aortic arch was type A in 17 patients and type B in 3 patients. Aortopulmonary window morphology was type I (n = 10), type II (n = 5), and type III (n = 5). Associated cardiovascular anomalies were common, including atrial septal defect (n = 13) and systemic venous anomalies (n = 3). Overall survival after initial admission was 91%, 86%, and 84% at 1, 5, and 10 years, respectively. Fifteen patients underwent single-stage repair, and 4 patients underwent staged repair. There was an increased prevalence of patch augmentation of the interrupted aortic arch anastomosis in lower-weight infants (2.3 kg vs 3.1 kg, P = .07). Competing risk analysis estimated that 5 years after repair, 51% had initial arch reintervention, 6% had initial pulmonary artery reintervention, and 43% were alive without reintervention. Reintervention for arch obstruction was more likely for those with interrupted aortic arch type B (P = .08) and for those with higher weight at initial repair (P = .003). CONCLUSIONS: Complete correction of aortopulmonary window in the setting of interrupted aortic arch can be performed with low mortality in the neonatal period. Reinterventions for aortic arch obstruction are the most frequent complication after repair, but pulmonary artery stenosis also occurs. Use of patch augmentation may reduce the need for subsequent arch reintervention.

Aorta, Thoracic↗

PubMed2006

Are allografts the biologic valve of choice for aortic valve replacement in nonelderly patients? Comparison of explantation for structural valve deterioration of allograft and pericardial prostheses.

OBJECTIVE: To compare explantation for structural valve deterioration in nonelderly patients after aortic valve replacement with stented bovine pericardial and cryopreserved allograft valves. METHODS: From 1981 to 1985, 478 patients received pericardial prostheses during premarket approval; from 1987 to 2000, 744 patients received cryopreserved allografts. Mean age of patients receiving allografts was 49 +/- 12 years, and that of those receiving pericardial prostheses was 65 +/- 11 years; pericardial valves were used in 138 patients younger than age 60. Mean follow-up was 15 +/- 5.1 years for pericardial valves (4674 patient-years of follow-up) and 5.6 +/- 3.1 years for allografts (3892 patient years of follow-up). Multivariable hazard function methodology, age-group stratification, and propensity matching were used to compare age-specific explantation for structural valve deterioration. RESULTS: Ninety-five pericardial valves and 46 allografts were explanted, and structural valve deterioration was the mechanism of failure in 74% and 59%, respectively. The risk of structural valve deterioration increased with younger age at implantation for both allografts (P = .07) and pericardial valves (P < .0001), with a similar magnitude of effect in patients age 50 years or younger (P = .5), 50 to 60 years (P = .7), and greater than 60 years (P = .9) and in propensity-matched pairs (P = .2). Thus, pericardial valves were as durable as allografts at all adult ages. CONCLUSIONS: Structural valve deterioration is the most frequent cause of valve-related reoperation after both pericardial and allograft aortic valve replacement and is similarly age dependent, suggesting that pericardial valves may be appropriate for nonelderly as well as older persons.

Adult↗

PubMed2006

Duration of inotropic support after left ventricular assist device implantation: risk factors and impact on outcome.

OBJECTIVES: Because duration of inotropic support after left ventricular assist device implantation has been recognized as a surrogate for right ventricular dysfunction, we sought to (1) identify its preimplantation risk factors, particularly its association with preimplantation right ventricular dysfunction, and (2) assess its impact on clinical outcomes. METHODS: Between 1991 and 2002, left ventricular assist devices were implanted in 207 patients, exclusive of those receiving preoperative mechanical circulatory support, which precluded measuring right ventricular stroke work. Duration of inotropic support was analyzed as a continuous variable, truncated by death or transplantation, and in turn as a risk factor for these 2 events. RESULTS: Inotropic support decreased from 100% on the day of implantation to 57%, 33%, and 22% by days 7, 14, and 21. Its duration was strongly associated with lower preimplantation right ventricular stroke work index, older age, and nonischemic cardiomyopathy and was associated (P < .04) with higher mortality before transplantation but not with transition to transplantation. We identified no preimplantation risk factors for right ventricular assist device use because of its relatively infrequent use in this population (18 patients, only 4 of whom survived to transplantation). CONCLUSION: Duration of inotropic support after left ventricular assist device insertion is strongly correlated with low preimplantation right ventricular stroke work index. In turn, it was associated with reduced survival to transplantation. Thus, right ventricular stroke work measured before implantation might be useful in decision making for biventricular support, destination therapy, or total artificial heart.

Cardiomyopathies↗