Cause Of Reintervention Research Articles

Experiencia de 10 años en la cirugía del canal auriculoventricular

ObjectiveThe purpose of this study was to evaluate the surgical outcome of the atrioventricular septal defect in a single institution during the last 10 years (2003-2013) and to identify the risk factors associated with poor outcome. MethodsData were retrospectively collected on 91 consecutive patients who underwent surgical correction for atrioventricular septal defect between May 2003 and October 2013 at our institution. There were 10 patients with borderline unbalanced forms of AVSD (0.19≤atrioventricular valve index≤0.39) that were repaired with a two-stage strategy. ResultsThe overall mortality was 3.30% (n=3). In-hospital mortality was 1.10% (n=1), and late mortality was 2.20% (n=2). The overall re-intervention was 11% (n=10). Early reoperation was indicated in one patient. and late reoperation was required in 9 patients. Left atrioventricular valve regurgitation was the leading cause for re-intervention. The estimated overall survival at 10 years of follow-up for all patients was 96.70%. The estimated survival in the unbalanced group was 100%. The estimated freedom from late reoperation for all hospital survivors without an early reoperation was 89% at 10 years. ConclusionsAtrioventricular septal defect is optimally carried out with good mid-term outcome. However postoperative left atrioventricular valve regurgitation remains a matter of concern during follow-up. Down's syndrome could be a protective factor against this complication. Palliatives techniques may be useful in borderline unbalanced forms of AVSD in order to achieve a biventricular repair.

Long-term results of the Ross procedure in a population-based follow-up.

The purpose of this study was to evaluate the long-term outcomes of the Ross procedure in a nationwide follow-up. This retrospective study involved all children treated with the Ross procedure in Finland between 1994 and 2009. The clinical records were reviewed for demographic and anatomical characteristics, Ross operation data, surgical history and status at the latest follow-up. The median follow-up time was 11.5 (range 2.4-19.2) years. Fifty-one patients underwent either the Ross (n = 37) or the Ross-Konno (n = 14) procedure at a median age of 4.8 (range 0.02-16.3) years, including 13 infants (<1 year of age). The indication for the Ross procedure was aortic valve stenosis, regurgitation or both, which was observed in 29, 24 and 47% of patients, respectively. The early mortality (before hospital discharge) rate was 10% (31% in infants) and the late mortality rate 6% (15% in infants). Higher mortality was discovered in patients treated with the Ross-Konno procedure (P = 0.001). The most common cause for reintervention was pulmonary homograft stenosis. The rate of freedom from right ventricular outflow tract reintervention was 98% at 5 years, 83% at 10 years and 59% at 15 years. The rate of freedom from autograft reintervention was 98% at 5 and 10 years, and 81% at 15 years. At the latest follow-up visit, mild-to-moderate aortic root dilatation was reported in 52% of patients, and 4 patients had undergone autograft-related reinterventions. Trivial autograft valve regurgitation was commonly seen, but only 1 patient developed severe autograft regurgitation requiring mechanical valve replacement 15.9 years after the Ross operation. The most common reason for reintervention after the Ross procedure in children is homograft stenosis. Aortic root dilatation and autograft valve regurgitation are relatively common but rarely lead to reinterventions before adulthood. Intraoperative complications and complex cardiac anatomy are associated with high mortality in infants undergoing the Ross-Konno procedure. In our centre, the Ross procedure has provided good long-term results in this challenging group of paediatric patients.

Durability of the Endurant stent graft in patients undergoing endovascular abdominal aortic aneurysm repair

Several studies have confirmed the excellent early performance of the Endurant (Medtronic Endovascular, Santa Rosa, Calif) endoprosthesis to treat abdominal aortic aneurysms (AAAs). However, data about the long-term durability of the device are still lacking. We conducted this prospective two-center single-arm study to assess the late outcomes of the endograft in patients undergoing AAA repair. An intention-to-treat analysis was performed for all comers with AAAs who were implanted with an Endurant endograft between November 2007 and December 2010. Clinical and radiologic data were prospectively collected and analyzed. The primary end point was any AAA-related reintervention. Secondary end points were overall mortality, aneurysm shrinkage, all types of endoleak, and device-related complications. During the study period, 273 patients underwent implantation of the Endurant stent graft. The median follow-up time for the primary end point was 42months (interquartile range, 30.7-50.7). AAA-related reinterventions were required in 26 patients (10%), resulting in a reintervention-free probability of 93%, 90%, and 87% at 3, 4, and 5years, respectively. The leading cause for reintervention was iliac limb occlusion (n= 10). Only one AAA-related death (0.3%) was reported within an overall mortality of 29% (n= 78). The median aneurysm shrinkage was 9mm (interquartile range, 3-15). Five type I (2%) and one type III (0.4%) endoleaks were identified. No proximal and two distal limb migrations (1%) were observed. Our study confirms late durability of the Endurant endoprosthesis for AAA repair, with very encouraging freedom from reintervention rates and overall outcomes.

Invited Commentary

Hopkins and colleagues [1] report the use of decellularized pulmonary homograft patch material in 106 patients, predominantly for pulmonary arterioplasty. No material related failure or reoperation was noted at 1.8-year follow-up. A historical group of 100 patients, having mostly cryopreserved or polytetrafluoroethylene (PTFE) patches for pulmonary arterioplasty, served as controls. The overall reintervention incidence was similar (17% study group versus 14% control group). Material failure was noted as the cause of reintervention in the control group.

Feasibility of Endovascular Abdominal Aortic Aneurysm Repair Outside of the Instructions for Use and Morphological Changes at 3 Years after the Procedure

We retrospectively analyzed outcomes of patients who had undergone endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) more than 3 years previously in a single institution. We compared outcomes between patients who underwent EVAR within and outside of the devices' instructions for use (IFU) and examined mid-term morphological changes in AAA. A total of 275 patients who underwent EVAR for AAA were selected. IFU parameters included aneurysmal neck length, angulation and presence of massive atheroma. Patients were divided into 2 groups: the Within IFU group (W-IFU: n = 193) and the Outside of IFU group (O-IFU: n = 82). Patients in the O-IFU group were older and had a larger AAA diameter. Other comorbid factors were similar between the 2 groups. There was no difference in overall survival rates and reintervention rates between the 2 groups. The most common cause for reintervention was AAA enlargement 3 years after EVAR. Irrespective of the IFU, mid-term morphological changes, including neck angulation, neck diameter, sac re-expansion, and Palmaz stent displacement, were found. Outcomes of EVAR were considered acceptable in the O-IFU group. Careful follow-up is necessary considering the morphological changes in AAAs after EVAR.

Comparison of attachment site endoleak rates in Dacron versus native aorta landing zones after thoracic endovascular aortic repair

Type I attachment site endoleaks are the most common cause for reintervention after thoracic endovascular aortic repair (TEVAR) and represent treatment failures. Deployment of endografts in segments of the aorta previously replaced with Dacron grafts may be associated with reduced type I endoleak due to mechanical stability and decreased potential for aortic remodeling. However, no study has rigorously examined endoleak rates in Dacron landing zones vs native aorta. A retrospective analysis of a prospectively maintained database was performed to identify all patients undergoing TEVAR at a single referral institution between May 2002 and June 2012. Overall, 319 patients undergoing 345 procedures had at least one follow-up contrast-enhanced computed tomography scan to assess for postoperative type I endoleak. Attachment site landing zones were classified as native aorta, Dacron, or endograft if landed in a previously placed endograft. Patient characteristics and type I endoleak rates were compared among the three groups. Identified were 697 proximal or distal landing zones (native aorta, 599; Dacron, 79; and endograft, 19). Patients with at least one Dacron landing zone had higher rates of hypertension (P < .01), chronic obstructive pulmonary disease (P = .04), and prior aortic surgery (P < .01) and were more likely to have undergone complex hybrid repairs (P < .01). Cumulative type I endoleak rates were equivalent between the three types of landing zone (native aorta, 3.7%; Dacron, 2.5%; endograft, 0%; P = .44). Two type I endoleaks occurred with Dacron landing zones in the first tertile of TEVAR experience and with Dacron landing zone lengths of <2.5 cm. Evaluation of endoleak rates by tertile of experience demonstrated decreased type I endoleak rates in Dacron landing zones between the first and second/third tertiles of experience (13.3% vs 0%, P = .03) after a policy of using >4 to 5 cm (twice the device instructions for use) of Dacron overlap was initiated. Endograft deployment within long-segment (landing zone length of >4-5 cm) Dacron represents a durable option for aortic repair and was associated with a 0% rate of type I endoleak. In cases of a borderline native aortic landing zone, a hybrid procedure to create an adequate Dacron landing zone may be warranted to decrease the risk of type I endoleak and treatment failure.

ITalian Excluder Registry and results of Gore Excluder endograft for the treatment of elective infrarenal abdominal aortic aneurysms

To report the midterm results of elective endovascular aortic repair (EVAR) of abdominal aortic aneurysms (AAAs) in a multicenter, clinical unsponsored registry using the Gore Excluder endograft. This study is a retrospective analysis of a multicenter, prospective registry that involved nine centers in Italy. Periodic clinical and radiographic follow-up with computed tomography scans were performed at 1, 6, and 12 months after the procedure, and on a yearly basis thereafter. A total of 872 patients underwent elective EVAR. Primary technical success was 97.5%, and hospital mortality was 1.0% (9/872). At least 816 (93.6%) patients underwent a follow-up control. Freedom from all-cause death was estimated to be 97.9% at 1 year, 93.4% at 3 years, and 88.5% at 5 years. Aneurysm-related mortality was 1.6% (n = 13) with only two late AAA-related deaths observed at 21 and 36 months. Significant predictors of all-cause mortality included age (P < .001) and AAA maximum diameter (P = .027). Overall conversion rate was 2.3% (n = 19). Mean elapsed time from initial intervention to surgical conversion was 23 ± 18 months (range, 0-52 months). Late rupture was detected in four (0.5%) cases: two of these patients died after conversion. The rate of any reintervention was 9.4% (n = 77); most of them were required within the first 24 months. The leading cause of reintervention was endoleak (n = 41; 5.0%). Limb thrombosis occurred in nine (1.1%) cases. Freedom from reintervention at 1, 3, and 5 years of follow-up were 98.6%, 94.6%, and 86.5%. The ITalian Gore Excluder Registry is the largest clinical unsponsored registry using a single device, with the longest follow-up period so far. The present experience confirms the effectiveness of EVAR using the Gore Excluder with low rates of mortality, migration, reintervention, and limb thrombosis.

Pulmonary valve replacement after correction of Tetralogy of Fallot

Background The Tetralogy of Fallot (TOF) is a frequent cardiopathy in our days, corresponding to 7% of the congenital cardiopathies. However it is acknowledged that one of the main causes of reintervention in these patients is the presence right ventricular failure secondary to pulmonary valve insufficiency (IP) leading the patient to intolerance to exercise, ventricular tachycardia and sudden death. The aim of our investigation is describing our experience of those patients subjected to (TOF) correction who have required a pulmonary valve replacement.

Results of Thoracic Endovascular Aortic Repair 6 Years After United States Food and Drug Administration Approval

Since United States Food and Drug Administration approval in 2005, the short-term safety and efficacy of thoracic endovascular aortic repair (TEVAR) have been established. However, longer-term follow-up data remain lacking. The objective of this study is to report 6-year outcomes of TEVAR in clinical practice. A prospective cohort review was performed of all patients undergoing TEVAR at a single referral institution between March 2005 and May 2011. Rates of reintervention were noted. Overall and aortic-specific survival were determined using Kaplan-Meier methods. Log-rank tests were used to compare survival between groups. During the study interval, 332 TEVAR procedures were performed in 297 patients. Reintervention was required after 12% of procedures at a mean of 8 ± 14 months after initial TEVAR and was higher in the initial tercile of patients (15.0% vs 9.9%). The 6-year freedom from reintervention was 84%. Type I endoleak was the most common cause of reintervention (5%). Six-year overall survival was 54%, and aorta-specific survival was 92%. Long-term survival was significantly lower than that of an age- and sex-matched United States population (p < 0.001). Survival was similar between patients requiring a reintervention vs those not (p = 0.26). Survival was different based on indication for TEVAR (p = 0.007), and patients with degenerative aneurysms had the lowest survival (47% at 6 years). Cardiopulmonary pathologies were the most common cause of death (27 of 93 total deaths). Long-term aortic-related survival after TEVAR is high, and the need for reintervention is infrequent. However, overall long-term survival is low, particularly for patients with degenerative aneurysms, and additional work is needed to identify patients unlikely to derive a survival benefit from TEVAR.

Cirugía colorrectal en pacientes mayores de 65 años

There is a limited functional reserve in patients over 65 years of age which is conducive to more frequent postoperative complications. Disease extension at the time of diagnosis (clinical stage) and complete tumor resection are two independent risk factors that have a direct influence on survival. To describe the factors that influence morbidity and mortality in patients over 65 years of age after colorectal surgery. A retrospective, observational, descriptive study was carried out within the time frame of January 2004 and December 2009 on 105 colon cancer patients after colorectal surgery. They were divided into two groups, one under 65 years of age and the other over 65 years of age, in order to compare preoperative comorbidity, as well as morbidity and mortality 30 days after surgery. Of the 105 patient total (53,3%), 56 were ≤ 65 years of age. There were complications in 42,8% of the patients, and those of early and less severe presentation were the most frequent; late complications were more frequent in patients ≤ 65 vs > 65 years of age (16,0% vs 10,2%). Overweight (BMI > 25 kg/m(2)) was observed in 35,0% of the study population. Patients > 65 years of age had fewer comorbidities. The most common causes of reintervention were anastomosis dehiscence and postoperative hemorrhage. Mortality in the group was 6,6% and sepsis was the most frequent cause of death. Colorectal surgery in patients over 65 years of age has an acceptable complication frequency and a low mortality rate. Our results suggest that patients older than 65 years of age be treated with the same prospects for cure as younger patients.

Atomic force microscopy investigations on pits and debris related to fretting-corrosion between 316L SS and PMMA

In the case of hip prostheses, debris generation, due to the fretting-corrosion phenomenon between the femoral stem and the bone cement is one of the most significant causes of reintervention. In this study we use atomic force microscopy (AFM) to analyze PMMA particles and pitting corrosion on 316L SS as a function of chlorides and albumin concentration. Without albumin, the number of pits increases with the chlorides concentration. Contrary to the protective effect of albumin on global corrosive wear, albumin tends to increase the number of pits. The number of ejected particles highly depends on electrochemical conditions and the in vivo conditions, Open Circuit Potential, seem to lead to a small number of particles. This work has also explored atomic force microscopy as a “new” characterization technique for wear debris and demonstrates that 80% of particles have a size inferior to 100nm, which is the ‘critical size’ for tissues response.

Imaging of patients with congenital heart disease

Congenital defects most-commonly affect the heart, with an estimated incidence of up to 10 in 1,000 live births. Over the past few decades, mortality has decreased and subsequent survival has increased; approximately 90% of all patients with congenital heart disease (CHD) reach adulthood. Echocardiography is sufficient in most cases for prenatal and postnatal diagnosis of CHD and to plan an intervention, with cardiac MRI and CT providing complementary information on vascular and extracardiac abnormalities. During follow-up, cardiovascular dysfunction is an important cause of reintervention and death. Therefore, routine evaluation of systolic, diastolic, valvular, and vascular function is essential in the care of patients with CHD. Application of echocardiography, cardiac MRI, and CT during follow-up of patients with CHD ideally identifies patients at risk of adverse outcomes, and elucidates the pathophysiological mechanisms that underlie cardiovascular dysfunction. The advent of advanced imaging strategies might further improve the detection of subclinical cardiovascular failure, although further study is required to establish the value of these techniques. Finally, imaging beyond the heart is essential for the complete understanding of the interaction between CHD and noncardiac organ systems, and to extend the success of increased survival to improvements in long-term functional outcome.

Secondary Procedures After Aortic Aneurysm Repair With Fenestrated and Branched Endografts

To investigate the secondary procedures in patients with previous endovascular aortic repair by fenestrated or branched stent-grafts for aneurysms involving the renal and visceral vessels. Between January 2001 and May 2010, 107 consecutive high-risk patients (97 men; mean age 73 years, range 50-86) with aortic aneurysms involving the renal and visceral arteries were treated with endovascular techniques. A custom-made Zenith graft was used in all patients. All secondary graft-related procedures performed in the perioperative period and during follow-up were analyzed. Estimates of survival, freedom from migration/type I endoleak, and freedom from any device-related secondary procedures were assessed with Kaplan-Meier analyses. The 30-day mortality rate was 1.9%. During follow-up (mean 25 months, range 1-94), 34 secondary procedures were performed in 28 (26.2%) patients for 6 (17.6%) limb graft stenoses/thromboses (5.6% of 107 cases), 8 (23.5%) in-stent visceral vessel stenoses/occlusions (7.5% of 107 cases), 8 (23.5%) migrations/type I endoleaks with/without visceral stent fractures (7.5% of 107 cases), and 12 (35.3%) type III endoleaks (9.3% of 107 cases). The mean interval between the primary and secondary procedures was 12.9 months (range 1-68). In 26 (76.5%) of 34 cases, a secondary endovascular procedure was performed; in the remaining 8 (23.5%) cases, the complication was treated surgically. The secondary procedure was unsuccessful in 9 cases of visceral vessel compromise (failure to cannulation, stent fracture/migration, in-stent stenosis/occlusion). Estimated 3-year survival was 77%, while the 3-year rate for freedom from any device-related secondary procedure was 75.5%. The incidence of early and late complications requiring a secondary procedure after treatment with fenestrated or branched devices was not negligible. Endoleak type III represented the most common cause for reintervention during follow-up. Secondary procedures performed for visceral vessel compromise had high rates of treatment failure. Accurate preoperative planning, the advent of new materials/techniques, and strict follow-up could be the key factors to improving the results of fenestrated or branched stent-graft interventions and to reduce the rate of secondary procedures.

Long-term outcome of open or endovascular repair of abdominal aortic aneurysm

Study objective: To evaluate long-term outcomes of endovascular or open abdominal aortic aneurysm (AAA) repair in patients who were enrolled in the Dutch Randomized Endovascular Aneurysm Repair (DREAM) study. Study population: Patients were eligible for DREAM if they had an AAA measuring at least 50 mm in diameter, and were considered candidates for either mode of repair. Patients were excluded if they required emergency aneurysm repair, had inflammatory aneurysms, anatomic variations precluding repair, connective tissue disease, previous organ transplantation or a life expectancy of less than 2 years. Suitability for endovascular repair was primarily based on anatomic criteria. Patients were deemed suitable for open repair based on the opinion of a cardiologist or internist. Design and methods: This study is a secondary analysis of long-term outcomes of patients enrolled in the DREAM study, a multi-centered, randomized, clinical trial. Randomization initially occurred in a 1:1 ratio via computer algorithm, and was stratified according to center in a permuted-block sequence of four patients. While the original analysis of DREAM examined short-term mortality and complications, the primary outcomes outlined in this analysis were long-term death from any cause and the need for repeat intervention. A reintervention was defined as a repeat procedure related to the initial repair secondary to a graft (e.g. prosthesis infection or type 1 endoleak), wound (e.g. incisional hernia or wound infection), or local or systemic complication. The primary analysis was intention to treat. After the second year of enrollment, patients received biannual questionnaires evaluating physical health and utilization of medical resources, with additional data collected based on routine clinical care. At the conclusion of the study period, follow-up was attempted on all patients either directly, or through their relatives or physicians. Results: The DREAM study randomly enrolled 178 patients to undergo open repair and 173 patients to undergo endovascular repair. Data collection for this analysis was stopped after a mean follow-up of 6.4 years (CI: 5.1 to 8.2). Baseline characteristics were similar in both groups regarding associated cardiac disease and cardiovascular risk factors. Long-term follow-up was high in both the open repair group (99.3%) and endovascular group (99.7%). At the conclusion of the study, overall survival rates were 69.9% in the open repair group and 68.9% in the endovascular group ( p = 0.97, 95% confidence interval (CI): —8.8 to 10.8). Freedom from reintervention was significantly higher in the open repair group compared to the endovascular group (81.9% vs 70.4%, p = 0.03; 95% CI: 2.0 to 21.0). The most common cause for reintervention in the endovascular group was endograft related (75.0%). Patients in the open group most commonly underwent reintervention for an incisional hernia (46.7%). Conclusions: Endovascular and open repair for AAA have similar survival outcomes at 6 years. There is an increased rate of reintervention associated with endovascular repair, primarily due to graft-related complications.

Late Results After Extended Pulmonary Artery Reconstruction in the Arterial Switch Operation

Pulmonary artery stenosis remains the most frequent late complication and cause of reintervention after the arterial switch operation for transposition of the great arteries. We investigated the influence of an extended pericardial patch augmentation of the neopulmonary root and pulmonary artery on late pulmonary artery stenosis development. Augmentation of the neopulmonary root and pulmonary artery was achieved by reconstructing the posterior wall using a large glutaraldehyde-treated autologous pericardial patch. Reviewed were regular follow-up echocardiograms from 58 out of 87 patients undergoing the arterial switch operation who presented a follow-up period of at least 5 years. An actual follow-up echocardiographic evaluation focusing on the maximal instantaneous transpulmonary continuous-wave (cw)-Doppler gradient was performed, followed by cardiac catheterization when indicated (peak cw-Doppler gradient > 40 mm Hg). Follow-up was 8.9 [5 to 15] years. There was no reintervention due to residual pulmonary artery stenosis. Actual Doppler examination revealed a transpulmonary peak gradient of 19.5 [0 to 56] mm Hg, compared with 20 [0 to 60] mm Hg at discharge. Forty-three patients (74.1%) had no or only trivial pulmonary artery stenosis (pressure gradient < 25 mm Hg), 14 patients (24.2%) had mild stenosis (25 to 49 mm Hg), and 1 patient (1.7%) had moderate stenosis (50 to 79 mm Hg). Compared with the majority of literature data, we could demonstrate a low incidence of late pulmonary artery stenosis after the arterial switch operation by employing an extended pericardial patch reconstruction technique with augmentation of the neopulmonary root and pulmonary artery.

Results of arterial switch operation for primary total correction of the Taussig-Bing anomaly

Background This study evaluates the results of the arterial switch operation for early total repair of double-outlet right ventricle with subpulmonary ventricular septal defect (the Taussig-Bing heart). Methods From 1986 through April 2003, 27 patients with Taussig-Bing anomaly underwent arterial switch operation. Twenty patients were neonates (n = 11) or infants younger than 3 months (n = 9). Obstruction of aortic arch (n = 19) or subaortic right ventricular outflow tract obstruction (n = 20) and unusual coronary artery patterns (n = 19) were common. Total correction as a single procedure was performed in 21 patients. Events are depicted by Kaplan-Meier curves. Results There was 1 patient hospital death at 2 months after repair. One patient died late that was not cardiac related. Survival was 92% ± 6% at 8 months and remained constant thereafter. Four patients underwent reoperation (1 for residual aortic arch obstruction and 3 for subvalvular and valvular pulmonary stenosis). Freedom from reoperation decreased to stabilize at 83% ± 8% after 2 years. The risk to have right ventricular outflow tract obstruction develop was 33% ± 10% at 1 year, increasing slowly and leveling out at 57% ± 12% at year 5 and thereafter. Statistical analysis revealed no significant risk factor for death or need for reoperation. Conclusions The Taussig-Bing anomaly should be corrected in the neonatal period or in early infancy by arterial switch operation, closure of the ventricular septal defect, and simultaneous correction of associated cardiovascular anomalies as a one-stage procedure. Right ventricular outflow tract obstruction often complicates the postoperative course and is the main cause for reintervention.

An unusual cause for reintervention after coronary artery bypass grafting

A CUTE myocardial infarction (MI) may be followed by severe complications leading to rapid hemodynamic deterioration. Well-known examples are pump failure secondary to loss of left ventricular mass, ventricular fibrillation, ventricular septal rupture, and papillary muscle rupture. Any patient with a recent MI who has to undergo coronary artery bypass grafting (CABG) because of postinfarction angina can sustain these complications in the postoperative period. This case describes a patient who developed cardiovascular collapse in the early postoperative period of a CABG, probably as a sequela of the recent myocardial infarction.