Excellent Hemodynamic Results Research Articles

A premounted stent that can be implanted in infants and re‐dilated to 20 mm: Introducing the Edwards Valeo Lifestent

Intravascular stenting (IS) for vascular stenoses in congenital heart disease provides superior gradient relief and angiographic results over balloon angioplasty (BA) alone. The advantages of IS, however, are difficult to apply to infants, toddlers, and small children due to technical challenges in placing large, long sheaths and the risk of creating future stenoses in stents that cannot be re-dilated to keep pace with somatic growth. This report highlights the Edwards premounted re-dilatable biliary stent, which was safely placed in four infants and small children with excellent hemodynamic and angiographic results. Bench testing revealed the stent has adequate radial strength and can be re-dilated to a maximal diameter of 20 mm.

Initial clinical manifestations and mid- and long-term results after surgical repair of double-chambered right ventricle in children and adults

By means of retrospective analysis of our institutional experience, we reviewed the clinical manifestation and outcomes of patients subsequent to surgical repair of double-chambered right ventricle. Between 1988 and 2005, we performed surgical repair in 35 of 37 patients diagnosed with double-chambered right ventricle. The patients ranged in age from 4 to 69 years, with a mean of 21.3 years. Most presented in infancy, with initial manifestation of a short systolic murmur in 34 (92%) of all cases. Pressure gradients were measured invasively across the right ventricular outflow tract of between 30 and 140 mmHg, with a median of 60 mmHg. An associated ventricular septal defect was present in 26 patients (70%). Of the group, 4 patients were aged over 40 years, and 2 had previously undergone operative closure of a ventricular septal defect. The operative interval ranged from 2 months to 41 years, with a median of 9 years. In all, we resected muscular bundles and enlarged the right ventricular outflow tract. There was no hospital or late death. Median follow-up subsequent to surgery was 7 years, with a range from 0.4 to 11 years. No patient required further surgery to relieve any obstruction of the right ventricular outflow tract, nor long term medical therapy or pacing because of cardiac arrhythmia. Surgical repair of a double-chambered right ventricle yields excellent haemodynamic and functional results over the mid to long term.

Early repair of hemitruncus: Excellent early and late outcomes

Anomalous origin of 1 of the branch pulmonary arteries from the aorta with 2 normal semilunar valves (hemitruncus) is a rare entity. There have been several small case series reported. We report here our single-institution surgical experience with hemitruncus from 1982 to 2006. A retrospective case review of all cases of conotruncal anomalies at Children's Hospital Boston revealed 16 patients with hemitruncus. Ten patients had surgery in the neonatal period (<30 days), 4 at 1 to 6 months, 1 at 8 months, and 1 at 2 years. Diagnosis of hemitruncus was the indication for operation in all but 1. Fourteen of the 16 had anomalous right pulmonary artery from aorta, and 2 had left pulmonary artery from aorta. Common associated anomalies included patent foramen ovale in 14, patent ductus arteriosus in 11, and ventricular septal defect in 4. All patients had elevated right ventricular pressures with systemic pressures in 5 and suprasystemic pressures in 9. There was 1 operative death in this series in an infant who died from sepsis following ligation of a tracheoesophageal fistula. One patient required reoperation for supravalvular aortic stenosis and right pulmonary artery stenosis 1 year postoperatively. Three patients required 4 catheter-based interventions postoperatively. At 20 years, survival by Kaplan-Meier was 93%; freedom from reoperation, 93%; and freedom from catheter reintervention, 79%. Early repair of hemitruncus results in excellent hemodynamic and anatomic results. Survival is excellent, with a low incidence of reoperation or reintervention.

The Ross Procedure: Clinical and Echocardiographic Follow-Up in 219 Consecutive Patients

The replacement of the diseased aortic valve with a pulmonary autograft has been shown to provide excellent hemodynamic results and to be associated with low morbidity and mortality rates. From 1991 to 2005, 219 patients undergoing the Ross operation were identified. All patients underwent transthoracic echocardiography at discharge and were scheduled for a yearly study thereafter. The echocardiographic study consisted of a morphologic analysis of the pulmonary autograft with measurement of end-systolic diameters at three levels: annulus, sinuses of Valsalva, and origin of the ascending aorta 2 cm above the sinotubular junction. The dynamic analysis evaluated the function of the aortic autograft and the pulmonary homograft. Maximal and mean aortic and pulmonary transvalvular pressure gradients were investigated. The 30-day mortality was 1.8% (n = 4). Cardiac deaths were not related to the autograft. The 10-year actuarial survival was 95.7% +/- 2.1%. Six patients (2.8%) had grade 2 autograft valve regurgitation. No grade 3 or 4 pulmonary regurgitation was identified. At their most recent follow-up, 28 patients (13.1%) had grade 1 insufficiency of the pulmonary homograft, and 10 patients (4.6%) had a peak transvalvular gradient of 17.9 +/- 10.2 mm Hg. Our current experience suggests that replacement of the aortic root with a pulmonary autograft can be safely performed in infants, children, and adults and is associated with low mortality and morbidity rates. It constitutes an elegant alternative to the use of prosthetic valves in the treatment of aortic valve diseases.

Percutaneous septal ablation with absorbable gelatin sponge in hypertrophic obstructive cardiomyopathy

The treatment of the hypertrophic obstructive cardiomyopathy (HOCM) by percutaneous transluminal septal myocardial ablation (PTSMA) with ethanol injection has greatly improved in the last years. This report describes the case of a patient with symptomatic drug-refractory HOCM who underwent an unsuccessful attempt to thrombose the septal artery by PTSMA with alcohol. It has therefore been decided to use small absorbant gelatin sponge (AGS) particles, obtaining immediate thrombotic occlusion of the artery and excellent hemodynamic results with immediate and permanent disappearance of the gradient. The patient progressed satisfactorily and displayed lower than average creatine kinase levels in comparison to the rest of our PTMSA patients. After 2 years of follow-up he still remains asymptomatic and without any gradient. These results suggest that PTSMA with AGS could be a valuable alternative treatment of HOCM.

Impact of Implantation Technique on Hemodynamic Results of the Pericarbon Freedom Stentless™ Valve

The Pericarbon Freedom stentless valve has shown excellent hemodynamic results in the midterm course. However, there is no information as to whether a continuous or interrupted suture technique at the inflow site has an impact on postoperative hemodynamics. 139 patients were enrolled in a non-randomized, prospective matched trial. An interrupted suture line technique was used in 68 patients and a continuous suture line technique was used in 71 at the inflow site. Isolated valve replacement was performed in 70.4% of the continuous and 67.6% of the interrupted suture group. Pre- and postoperative hemodynamics and one-year follow-up were obtained by echocardiography and expressed as mean and peak gradients and grade of regurgitation. No significant difference between continuous and interrupted suture techniques were noted with respect to mean (11.8 +/- 6.3 vs. 12.5 +/- 6.2 mm Hg, p = 0.251) and peak gradients (21.0 +/- 9.6 vs. 22.0 +/- 10.9 mm Hg, p = 0.292) as well as to the degree of regurgitation. Bypass and cross-clamping times decreased by 22.4 and 20.6 minutes, respectively, with the use of the continuous suture technique. One year follow-up showed a further, significant decrease of mean and peak gradients. The Pericarbon Freedom stentless valve appears to offer excellent postoperative performance. The suture line technique at the inflow site does not result in any hemodynamic differences.

Valved stentless composite graft: clinical outcomes and hemodynamic characteristics

Background The valved stentless composite graft has become well established in our hospital for replacement of the ascending aorta and aortic valve in elderly patients and those with contraindication for lifelong anticoagulation. This study was conducted to evaluate the postoperative hemodynamic characteristics and clinical outcomes after implantation of this device. Methods Between November 1998 and February 2001, 45 consecutive patients with a mean age of 69 years underwent implantation of a composite graft using a stentless valve prosthesis (Toronto SPV) incorporated in a collagen-coated Dacron tube (InterGard). The indication for surgery was aortic valve disease with an accompanying true aneurysm of the ascending aorta in 42 patients and a dissection of the aortic wall in 3 patients. Postoperative echocardiographic examinations were performed before discharge from the hospital and at the time of the follow-up. Mean follow-up duration was 18 months (range 3 to 30 months). Results There was no perioperative mortality. During follow-up, there were two noncardiac, nonvalve-related deaths. Echocardiographic evaluation before discharge and at follow-up demonstrated favorable hemodynamics of the valve prosthesis with mean transvalvular gradients of 8.5 ± 2.9 mmHg and 8.0 ± 3.1 mmHg, respectively. No regurgitation across the valve and no contact of the cusps with the Dacron tube were seen in any case. Conclusions A stentless composite graft for replacement of the aortic valve and ascending aorta offers excellent hemodynamic results and is a suitable device for patients in whom anticoagulation should be avoided.

Ross operation with a tissue-engineered heart valve

Background. The Ross procedure has gained increasing acceptance due to excellent hemodynamic results by replacing the diseased aortic valve with the viable autologous pulmonary valve. Consequently, the right ventricular outflow tract (RVOT) has to be reconstructed. In this report a viable heart valve was created from decellularized cryopreserved pulmonary allograft that was seeded with viable autologous vascular endothelial cells (AVEC). Methods. A 43-year-old patient suffering from aortic valve stenosis underwent a Ross operation on May 20, 2000, using a tissue engineered (TE) pulmonary allograft to reconstruct the RVOT. Four weeks before the operation a piece of forearm vein was harvested to separate, culture, and characterize AVEC. Follow-up was completed at discharge, 3, 6, and 12 months postoperatively by clinical evaluation, transthoracic echocardiography (TTE), and magnetic resonance imaging (MRI). Additionally, at 1-year follow-up a multislice computed tomographic scan was performed. Results. After four weeks of culturing 8.34×10 6 AVEC were available to seed a 27-mm decellularized pulmonary allograft. Trypan blue staining confirmed 96.0% viability. Reendothelialization rate after seeding was 9.0×10 5 cells/cm 2. TTE and MRI revealed excellent hemodynamic function of the TE heart valve and the neoaortic valve as well. Multislice computed tomography revealed no evidence of valvular calcification. Conclusions. After 1 year of follow-up the patient is in excellent condition without limitation and exhibits normal aortic and pulmonary valve function.

Usefulness of the cryolife o’brien stentless suprannular aortic valve to prevent prosthesis-patient mismatch in the small aortic root

ObjectivesThis study evaluated the occurrence of prosthesis-patient mismatch (PPM) after Cryolife O’Brien (CLOB) suprannular stentless valve replacement in patients with a small aortic root and its repercussions on the patient’s hemodynamic status and left ventricular mass regression. BackgroundThe correct management of the small aortic annulus is still controversial. Small aortic prostheses can lead to a PPM, which results in high gradients with important repercussions on the hemodynamic status. MethodsSeventy-two patients (mean age: 72.5 ± 6.2 years, 73.6% women) with a small aortic root (≤21 mm intraoperatively measured aortic annulus) had a CLOB valve implanted in the aortic position between November 1993 and July 2001 at our institution. Mean prosthesis size was 22.0 ± 0.8 mm. Patients underwent echocardiography preoperatively, at discharge, six months, one year and yearly thereafter. ResultsThe incidence of PPM at discharge was 22.2% (16/72); 18.7% were severe (effective orifice area index [EOAI] ≤0.65 cm/m2), 43.7% were moderate (EOAI = 0.66 to 0.75 cm/m2) and 37.6% were mild (0.76 to 0.85 cm/m2). At multivariable analysis, gender (p < 0.001), age (p = 0.015), body surface area (p < 0.001) and patient’s annulus index (p < 0.001) were significant factors influencing the occurrence of “transient” PPM. At one year the incidence of PPM was 0%. ConclusionsSuprannular CLOB valve yielded excellent hemodynamic results in patients with small aortic roots. This study demonstrates that PPM can be completely avoided when using the CLOB valve. The superior hemodynamics of this stentless valve are likely to be related to its suprannular design.

Repair of double-chambered right ventricle: surgical results and long-term follow-up

Background. We reviewed the outcomes of double-chambered right ventricle repair. Methods. Between 1969 and 1998, 40 patients underwent surgical repair of a double-chamber right ventricle. The patients ranged in age from 3 months to 52 years (mean, 12.8 ± 11.6 years). Right ventricular outflow tract pressure gradients were from 20 to 170 mm Hg (mean, 65.0 ± 38.5 mm Hg) An associated ventricular septal defect was present in 27 patients (67.5%). Four patients were older than 30 years of age. Results. There were no hospital or late deaths. Mean postsurgical follow-up was 16.5 ± 8.9 years (range, 2.5 to 31 years). No patient required further surgery to relieve obstruction of right ventricular outflow tract. Conclusions. Surgical repair of a double-chambered right ventricle yields excellent hemodynamic and functional results over both the short and long term.

Aortic allografts for left ventricular outflow tract replacement in children.

Aortic allografts provide many advantages in children requiring left ventricular outflow tract (LVOT) reconstruction. The low risk of thromboembolic events and freedom from the requirement for anticoagulation are primary benefits. Additionally, excellent hemodynamic results are possible even in the presence of multilevel obstruction. The pulmonary autograft has become the favored approach in most pediatric centers, as the limited longevity of the aortic allograft has now become apparent. However, some children are not candidates for the pulmonary autograft. Thus, the aortic allograft remains a useful aortic valve substitute in children. Using standard aortic root replacement (ARR) or extended aortic root replacement (EARR) techniques, aortic allografts can be used in any circumstance. Young age and small size are predictive of shortened valve longevity and higher operative mortality compared with older children. Reoperation to replace a degenerated aortic allograft can be accomplished safely. Copyright 2000 by W.B. Saunders Company

Repair of cor triatriatum associated with partially unroofed coronary sinus

A young patient with cor triatriatum, secundum atrial septal defect, persistent left superior vena cava, partially unroofed coronary sinus, and moderate tricuspid regurgitation was documented to have both a left-to-right shunt from the common pulmonary venous chamber to the right atrium and a right-to-left shunt from the partially unroofed coronary sinus to the left atrium. Resection of the membrane dividing the left atrium, closure of the atrial septal defect and the partially unroofed coronary sinus with pericardial patches, and a tricuspid annuloplasty resulted in an excellent hemodynamic result.

Expanding indications for the Ross procedure

The pulmonary autograft procedure has been shown to provide excellent hemodynamic results in young patients with aortic pathology. However, the use of this procedure in those with more complex aortic disease has not been extensively evaluated. The purpose of this report is to present the application of the Ross procedure in a 21-year-old man with extensive acquired aortic root pathology, both subannular and supraannular, and prosthetic valve dysfunction after two previous procedures.

The Ross operation: a 12-year experience

Background. The Ross operation, originally introduced as a scalloped subcoronary implant with an 80% survival and 85% freedom from reoperation, has recently been modified to a root replacement which is now the most utilized implant technique. The mid and late results of this operative technique and comparison of intra-aortic implants and root replacement in a single institution are reported. Methods. The records of 328 patients who had a Ross operation at the University of Oklahoma (August 1986 to July 1998) were reviewed to assess operative technique and patient-related factors on survival, autograft valve function, homograft valve function, valve-related complications, and need for reoperation. Results. Operative survival was 95.4% with an actuarial survival of 89% ± 5% at 8 years. Freedom from replacement of the pulmonary autograft was 94% ± 3% at 8 years, freedom from reoperation on the pulmonary homograft was 90% ± 4% at 8 years, and freedom from autograft valve reoperation or dysfunction (3+ autograft valve insufficiency) was 83% ± 6% at 9 years. The incidence of autograft valve reoperation and late autograft valve dysfunction was decreased by root replacement. Annulus reduction and fixation improved early results in patients with aortic insufficiency and annulus dilatation. Conclusions. Early results have been excellent, as the development of late autograft valve dysfunction or dilatation has been rare. The excellent hemodynamic results with a limited incidence of reoperation and replacement of the autograft valve justify its continued use.

Brachytherapy for prophylaxis of restenosis after long-segment femoropopliteal angioplasty: pilot study.

To evaluate in a pilot study the feasibility and efficacy of endovascular brachytherapy for prophylaxis of restenosis after femoropopliteal percutaneous transluminal angioplasty (PTA) without stent implantation in a group of patients with a high risk of restenosis. Ten patients (six women, four men; mean age, 68 years) with long-segment (mean length, 16 cm; range, 9-22 cm) restenosis underwent PTA followed by endovascular irradiation with high-dose-rate afterloading of an iridium-192 rod. A dose of 12 Gy was targeted to the inner intimal layer of the vessel. Follow-up examinations until 12 months after PTA included measurement of the ankle-brachial index, color duplex ultrasonography (US) with calculation of the peak velocity ratio, and intraarterial angiography when recurrence was suspected. Irradiation was technically feasible in all patients without complications. In six patients, the dilated and irradiated segment remained widely patent at color US, with corresponding excellent hemodynamic and clinical results after 12 months. In four patients, clinical and laboratory findings indicated recurrence and arteriography demonstrated restenosis with a diameter reduction of 60%, 70%, 80%, or 90%. Considering the negative selection of patients with a high risk of restenosis, the results of our pilot study are promising concerning the possibility of reduction of restenosis by means of endovascular brachytherapy after long-segment femoropopliteal PTA without stent implantation. The value of this approach should now be determined definitively in randomized trials.

Direct Reconstruction of the Pulmonary Artery During the Arterial Switch Operation: An Interesting Surgical Option With Excellent Hemodynamic Results

Background. In transposition of the great arteries, reconstruction of the neo-pulmonary artery is a challenging surgical detail during the arterial switch procedure. We present early and midterm clinical and hemodynamic results of a direct reconstruction of the pulmonary artery avoiding prosthetic and autologous material. Methods. Between 1990 and June 1996, a total of 189 patients underwent the arterial switch procedure because of d-transposition of the great vessels. Of them, 47 underwent direct pulmonary artery reconstruction. Mean age at operation was 5.2 ± 4.1 days and mean weight was 3.75 ± 0.85 kg. Simple transposition of the great arteries was present in 13, transposition of the great arteries plus ventricular septal defect in 27, and more complex forms of transposition of the great arteries in 7 patients. The great vessels were side-by-side in 4 patients and in the anteroposterior position in 43 patients. The technique of direct pulmonary reconstruction includes extensive mobilization of both pulmonary artery branches into the hilum, posterior incision of the mean pulmonary artery into the bifurcation, and resuspension of the posterior commissure of the neo-pulmonary valve. A large anastomosis without any tension is then performed, using the anterior remnant aortic sinus of Valsalva to fit out the expected size of the neo-pulmonary artery. Results. Early mortality was 8.5% (4/47) in this particular group of patients. Postoperative echocardiography was performed before hospital discharge, 3 to 6 months postoperatively, and after a mean follow-up of 24 months. Of the 43 survivors, 37 patients had a pressure gradient across the pulmonary valve of less than 15 mm Hg. Mild pulmonary stenosis (pressure gradient of 15 to 30 mm Hg) was present in 4 and more severe supravalvar stenosis (pressure gradient > 30 mm Hg) in 2 patients. After a mean follow-up of 36 months, there was one redo operation to enlarge the right ventricular outflow tract. Conclusions. Direct reconstruction of the neo-pulmonary artery—avoiding autologous pericardium and prosthetic material—may represent an interesting option during the arterial switch operation when the great vessels lie in the anteroposterior position. This technique is simple, and the hemodynamic midterm results are very favorable. The incidence of postoperative supravalvar pulmonary stenosis is low, and there may be considerable potential for unlimited tissue growth.

Fontan Conversion To Cavopulmonary Connection And Arrhythmia Circuit Cryoablation

Objectives: We review our surgical experience patients with atriopulmonary Fontan operations who had obstructive or arrhythmia indications for conversion to total cavopulmonary artery connections, arrhythmia circuit cryoablation, and placement of atrial antitachycardia pacemaker. Methods: Fourteen patients (mean age 14 ± 4 years) had conversion to total cavopulmonary artery connection 8 ± 3 years after the original atriopulmonary Fontan operation primarily for atrial arrhythmias in 11, obstructive lesions in 2, and bradycardia with cyanosis in 1. Arrhythmia circuit cryoablation was performed on 11 patients and 10 had atrial antitachycardia pacemakers. Preoperative functional New York Heart Association class was IV in 9, III in 4, and II in 1. Results: One patient had brain death (7%) presumably caused by resternotomy complications despite an excellent hemodynamic result. Another required reoperation for a maldeployed clamshell device after attempted fenestration closure. Average length of stay was 10 ± 3 days; chest tubes were removed on day 7 ± 3. There were no long-term deaths (mean follow-up 1.7 years, range 5 months to 5 years). Postoperative arrhythmias occurred in five patients, three of whom had successful termination by antitachycardia pacemaker and two who had pharmacologic control of their respective junctional ectopic and slow atrial tachycardia. All patients have improved to New York Heart Association class I or II. Conclusions: Total cavopulmonary artery conversion in association with arrhythmia circuit cryoablation and atrial antitachycardia pacemaker placement can be accomplished with low morbidity and mortality, oftentimes resulting in dramatic increases in functional class and control of life-threatening arrhythmias.(J Thorac Cardiovasc Surg 1998;115:547-56)

Stenting for pulmonary artery stenosis following the ross procedure

A 34-year-old woman showed the development of significant main pulmonary artery obstruction along the supravalvar suture line 18 months following a Ross procedure. The patient underwent unsuccessful balloon angioplasty, followed by successful stent implantation. The angiographic narrowing disappeared postprocedure, and the excellent hemodynamic result maintained at 4 month follow-up.

The O'Brien-Angell stentless porcine valve: Early results with 150 implants

From August 1991 to June 1994, 150 patients underwent aortic valve replacement with the O'Brien-Angell stentless porcine xenograft (Bravo Cardiovascular Model 300, Cryolife, Atlanta, GA). To establish trends we analyzed three consecutive groups of 50 patients. We found significant differences in low postoperative gradients (mean < or = 10 mm Hg): 24% in group 1, 42% in group 2, and 96% in group 3. Comparing groups 1 and 3, gradients were significantly lower in all valve sizes. The difference is credited to better supraannular positioning of the valve, which is the key to the learning curve. Trivial central regurgitation was present in the three groups at 6%, 12%, and 0%, respectively. Peripheral regurgitation was trivial in 6%, 8%, and 0%, and mild to moderate in 4%, 2% and 0%, respectively. Seventy-eight of 107 patients with an available follow-up exceeding 1 year had noninvasive controls. Two early cases with moderate perivalvular leaks evolved to moderately severe leaks. Two valves were explanted. The O'Brien-Angell stentless valve is easy to handle and correct supraannular positioning provides excellent hemodynamic results.

A New Modification of Debridement Valvuloplasty for Acquired Aortic Valve Disease

A high speed electric rasp was used to remove fibrous thickening from the aortic valve in conjunction with aortic valve commissurotomy in ten patients. All patients had moderate rheumatic aortic valve disease combined with severe mitral valve disease, and were treated by mitral valve replacement and aortic valve repair. All patients survived the operative procedure. There were no deaths or complications during hospitalization related to the valve repair process. The transaortic valve gradient was relieved from an average of 21.0 +/- 8.6 mmHg to 5.6 +/- 4.0 mmHg (catheterization), and from moderate to less-than-mild stenosis (echocardiography). Aortic valve regurgitation was reduced from an average of 2.2+ to 0.7+ on a scale of 0 to 4+ (aortography), and from an average of 2.5+ to 1.1+ on a scale of 0 to 4+ (echocardiography). During the follow-up period, no patients were reoperated on because of aortic valve dysfunction. Follow-up echocardiographic study demonstrated that the transaortic pressure gradient and valvular regurgitation had not progressed, and immediate postoperative conditions were maintained. There were two late deaths not related to the aortic valve. One patient died of prosthetic valve endocarditis in the mitral prosthesis 14 months postoperatively, and the other of a cerebrovascular accident 21 months postoperatively. Based on these data, we believe that aortic valve repair with a high speed electric rasp can effectively relieve aortic stenosis, reduce valvular regurgitation, and provide an excellent hemodynamic result at early and mid-term follow-up.