Late Echocardiographic Follow-up Research Articles

Outcomes of Tricuspid Valve Repair With Artificial Neochordae in Pediatric and Adult Patients

BackgroundThere are sparse data on outcomes after expanded polytetrafluoroethylene artificial neochordae (ePTFE-AN) for tricuspid valve (TV) repair. We evaluated outcomes after TV repair with ePTFE-AN in both pediatric and adult patients. MethodsWe analyzed clinical data of 87 consecutive patients who underwent ePTFE-AN implantation at the time of TV repair from 1998 to 2020. Patients were categorized into pediatric and adult groups. ResultsThere were 29 pediatric (33.3%) and 58 adult (66.7%) patients. The most common etiology of tricuspid regurgitation (TR) was congenital (pediatrics: 86.2% [25 of 29]; adults: 39.7% [23 of 59]). The median number of pairs of ePTFE-AN implanted was 2 (interquartile range [IQR], 2-5 pairs) for pediatric and 3 (IQR, 2-4 pairs) for adult patients. There was no early death. Three adult patients (5.2%) required early TV reoperation, and 4 patients (1 pediatric, 3 adults) underwent late TV reintervention. Etiology of TR was congenital in 4 of the 6 adults who required TV reintervention. The 3-year cumulative risk of TV reintervention was 0.0% for pediatric and 7.3% (95% CI, 0.4%-14.2%) for adult patients. There was significant improvement in TR grade after TV repair at dismissal and at the latest echocardiographic follow-up in each group (P < .001). Severe TR developed in 1 pediatric patient and 7 adult patients during follow-up, and 6 (1 pediatric, 5 adults) of them underwent TV reoperation. ConclusionsePTFE-AN implantation in the TV position can be performed safely and effectively with no early death. In adult patients with congenital TR, patient selection is critical to achieve a durable outcome after TV repair.

Assessment of long-term structural deterioration of transcatheter aortic bioprosthetic valves

The durability of transcatheter aortic bioprosthetic valves is a crucial issue in the context of extension of indications in younger and lower-risk patients, but data are scarce, especially beyond 5 years of follow-up. The aim of this study was to evaluate the incidence of structural valve degeneration (SVD). Demographic, procedural, and in-hospital outcome data on patients who underwent transcatheter aortic valve implantation (TAVI) from 2002 to 2020 were obtained from our prospective institutional database. Patients in whom echocardiographic data were available both at baseline and follow-up post-TAVI were included. Clinical and echocardiographic follow-up were performed on site annually. Hemodynamic SVD was determined according to European task force committee guidelines. A total of 1824 patients (83.6 ± 6.8 years of age; 53% female) with paired post-procedure and late echocardiographic follow-up (median 1.9 years, max 10.9 years) were included. Among them, 223 (12.3%) patients have a follow-up of more than 5 years. A self-expandable valve was used in 160 (8.8%) patients while the remaining patients were treated with, a balloon-expandable valve (91.2%). Mean aortic gradient and effective aortic valve area remained unchanged during follow-up. SVD occurred in 16 (0.9%) patients. SVD was moderate in 8 (0.4%) patients and severe in 8 (0.4%) patients. Four (0.4%) patients required redo-TAVI for severe SVD. Our data do not demonstrate any alarm signal on transcatheter aortic valve durability. Careful prospective assessment in younger and lower risk patients and comparison with surgical bioprosthetic valves are required to further assess long-term durability of transcatheter valves.

Assessment of long-term structural deterioration of transcatheter aortic bioprosthetic valves

Abstract Background The durability of transcatheter aortic bioprosthetic valves is a crucial issue in the context of extension of indications in younger and lower-risk patients, but data are scarce, especially beyond 5 years of follow-up. This study sought to evaluate the incidence of structural valve degeneration (SVD) 5 to 10 years post-procedure. Methods Demographic, procedural, and in-hospital outcome data on patients who underwent transcatheter aortic valve implantation (TAVI) from 2002 to 2014 were obtained from our prospective institutional database. Patients in whom echocardiographic data were available both at baseline and 5 years post-TAVI were included. Clinical and echocardiographic follow-up were performed on site annually. Hemodynamic SVD was determined according to European task force committee guidelines. Results A total of 208 patients (82.5±7.6 years of age; 53% female) with paired post-procedure and late echocardiographic follow-up (median 5.3 years, range 5 to 11.4 years) were included. Eleven (5.3%) patients were treated with a self-expandable valve and 197 (94.7%) patients with a balloon-expandable valve. Mean aortic valve gradient and effective aortic valve area remained unchanged during follow-up. There were 2 cases (1.0%) of severe SVD 6 and 7 years after implantation requiring redo-TAVI. There were 4 cases (1.9%) of moderate SVD (mean 6.0 years post-implantation; range 5 to 7 years). Conclusions Our data do not demonstrate any alarm on transcatheter aortic valve durability. Careful prospective assessment in younger and lower risk patients and comparison with surgical bioprosthetic valves are required to further assess long-term durability of transcatheter valves. Funding Acknowledgement Type of funding source: None

Perceval Sutureless Aortic Valve Implantation: Midterm Outcomes

Because our center participated in the first-in-human trial with Perceval (LivaNova, Sallugia, Italy) in 2007, this series represents the longest available clinical follow-up (11 years) with sutureless technology in aortic valve replacement. We collected all clinical and echocardiographic follow-up in 468 consecutive patients who received Perceval at our institution between 2007 and 2017. In 57% of cases, surgery was combined with coronary artery bypass grafting (39%), mitral valve surgery (17%), or other procedures (13%). Mean age was 79 years, mean EuroSCORE II was 5.1 ± 5.5 (range, 0.8-67) and mean Society of Thoracic Surgeons score was 5.8 ± 5.5. Mean cross-clamp times for isolated and combined procedures were 39 and 79 minutes, respectively. Observed all-cause 30-day mortality was 3.2%, with an early stroke rate of 1.8%. Pacemaker implantation rate was 7.9% overall, but only 3.9% in patients without preexisting conduction or rhythm disorders. All-cause mortality at 1 and 2 years was 8.8% ± 1.3% and 13.2% ± 1.6%, respectively. At the latest echocardiographic follow-up (mean, 3 years; range, 1-11 years), peak and mean gradients were 23 ± 10 mm Hg and 13 ± 6 mm Hg, respectively. During follow-up, we explanted 5 valves for endocarditis, and none for structural valve degeneration. After more than 11 years of continued clinical use of the Perceval sutureless valve, we observe low mortality and stroke rates, with good hemodynamic behavior of the valve. None of our patients was reoperated for structural valve degeneration. Because of the key benefits of this rapid-deployment valve, it has an added value in surgical aortic valve replacement.

Long-term Performance of Fresh Autologous Pericardium for Mitral Valve Leaflet Repair

Glutaraldehyde-fixed autologous or bovine pericardial patches used for mitral valve leaflet reconstruction have been associated with late calcification. Fresh autologous pericardium (FAP) may be a durable alternative. Transthoracic echocardiography was used to assess valve function (regurgitation, mean pressure gradient, patch pliability, and calcification) in patients undergoing FAP mitral leaflet repairs. Pliability was scored between 1 (similar to native leaflets) and 4 (rigid). Calcification was scored between 1 (echobrightness similar to native leaflets) and 4 (very bright). Between 2002 and 2018, 62 consecutive patients (50% male, 51 ± 2 years, 69% infective endocarditis) underwent mitral valve repair with FAP, and Patch placement was on the anterior (31 of 62), posterior (27 of 62), or both (1 of 62) leaflets. Late echocardiographic follow-up was available for 43 of 62 patients (median follow-up, 3.6 years; range, 0.5-6 years). Average pliability scores were unchanged between discharge (1.2 ± 0.1) and follow-up (1.2 ± 0.2, P= .79). Average brightness scores increased modestly (predischarge, 1.6 ± 0.1; follow-up, 1.8 ± 0.1; P= .01). Three patients had recurrent severe mitral regurgitation, and 2 underwent reoperation, 1 at 1 year postoperatively for recurrent endocarditis and 1 at 6 years postoperatively for degenerative disease progression. At reoperation, patches were pliable, free from calcification, and comparable in thickness to adjacent native leaflet. One patient developed suture line leak, which was repaired. No other evidence of patch dehiscence, retraction, or aneurysm was observed. The 10-year freedom from reoperation of 82% and survival rate of 84% are comparable to repair with glutaraldehyde-fixed or bovine pericardial patches. FAP is an excellent substrate for complex mitral valve leaflet patch repairs and can be used with the expectation of durable, long-term valve function, without evidence of late patch calcification, stiffness, or aneurysmal degeneration.

Long-Term Durability of Transcatheter Aortic Valve Prostheses

BackgroundVery little is known about long-term valve durability after transcatheter aortic valve replacement (TAVR). ObjectivesThis study sought to evaluate the incidence of structural valve degeneration (SVD) 5 to 10 years post-procedure. MethodsDemographic, procedural, and in-hospital outcome data on patients who underwent TAVR from 2007 to 2011 were obtained from the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) registry. Patients in whom echocardiographic data were available both at baseline and ≥5 years post-TAVR were included. Hemodynamic SVD was determined according to European task force committee guidelines. ResultsA total of 241 patients (79.3 ± 7.5 years of age; 46% female) with paired post-procedure and late echocardiographic follow-up (median 5.8 years, range 5 to 10 years) were included. A total of 149 patients (64%) were treated with a self-expandable valve and 80 (34.7%) with a balloon-expandable valve. Peak aortic valve gradient at follow-up was lower than post-procedure (17.1 vs. 19.1 mm Hg; p = 0.002). More patients had none/trivial aortic regurgitation (AR) (47.5% vs. 33%), and fewer had mild AR (42.5% vs. 57%) at follow-up (p = 0.02). There was 1 case (0.4%) of severe SVD 5.3 years after implantation (new severe AR). There were 21 cases (8.7%) of moderate SVD (mean 6.1 years post-implantation; range 4.9 to 8.6 years). Twelve of these (57%) were due to new AR and 9 (43%) to restenosis. ConclusionsLong-term transcatheter aortic valve function is excellent. In the authors’ study, 91% of patients remained free of SVD between 5 and 10 years post-implantation. The incidence of severe SVD was <1%. Moderate SVD occurred in 1 in 12 patients.

Long-Term Results Following Pericardial Patch Augmentation for Incompetent Bicuspid Aortic Valves: A Single Center Experience

Many techniques for repair of bicuspid aortic valves have been described and long-term results differ considerably. The current study evaluates our institutional results using the pericardial patch augmentation technique with the aim of increasing coaptation height. From November 2002 through April 2015, 103 consecutive patients underwent aortic valve repair using pericardial patch augmentation for incompetent bicuspid aortic valve. Of them 26 were referred with an aortic valve regurgitation grade 1+ or 2+ and were excluded from the current report. The remaining 77 patients with a mean age of 42 ± 14 years and aortic valve regurgitation grade of 3+ or higher were included in this retrospective single-center study. The main step of operative technique is the partial correction of leaflet prolapse by leaflet plication and overcorrection of coaptation height augmenting the fused leaflet with an autologous pericardial patch. In 45 patients (58%) an isolated aortic valve repair was performed. The ascending aorta was dilated in 32 cases (42%), and the following procedures were used for correction: reduction aortoplasty (19 patients), the David procedure (11 patients), and ascending aortic replacement (2 patients). Long-term results were evaluated by echocardiography and standardized questionnaire. Mean follow-up was 4.9 ± 4.6 years. There was no perioperative or 90-day mortality. Survival at 5 and 10 years was 96.1% and 93.5%, respectively. Freedom from reoperation at 5 and 10 years was 94.8% and 93.5%, respectively. At the latest echocardiographic follow-up, 94% of patients had none to trivial aortic regurgitation and 6% showed aortic regurgitation greater than or equal to 2°. Mean aortic gradients were 12.6 ± 9 mm Hg. One patients developed endocarditis 1 year after the procedure. There were no perioperative or long-term major neurologic events. The pericardial patch augmentation technique provides reliable long-term competence of reconstructed bicuspid aortic valves and results in a low reoperation rate, with other valve related complications being rare.

Ross procedure is a safe treatment option for aortic valve endocarditis: Long-term follow-up of 42 patients

BackgroundAortic root replacement with a pulmonary autograft (Ross procedure) can be performed as a treatment of aortic valve endocarditis, avoiding prosthetic valve implantation in septic context. We sought to assess long-term outcomes of the Ross procedure in this indication. MethodsFrom April 1992 to March 2009, the intervention was performed in 42 patients (mean age 34±8years) suffering from an active or ancient aortic valve endocarditis. 36% of the patients had extensive perivalvular involvement, and surgery was urgent in 18 patients (43%). We performed a prospective clinical and echocardiographic follow-up of this population. ResultsMedian follow-up was 10years (4–21years). Overall survival at 10 and 15years was respectively 87±5% and 81±8%. Perioperative mortality was 4.7% (2 patients) and no late cardiac death was reported. Eight patients (19%) underwent repeat surgery for autograft and/or homograft dysfunction at a median time of 8.4years (3months–18years). Rate of recurrent endocarditis was low (7%—3 patients), including 1 in a context of persistent intravenous drug abuse. Clinical follow-up showed good functional status for all patients with NYHA≤II, and less than 25% of patients requiring cardiovascular medication. Late echocardiographic follow-up demonstrated well-functioning autograft and homograft, with only one severe aortic regurgitation, and one significant increase in pulmonary mean gradient. ConclusionThe Ross procedure in aortic valve endocarditis is an interesting alternative to prosthetic valvular replacement in a selected population, with a high rate of survival free from any cardiovascular event or medication requirement.

Aortic Implantation of Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery: Long-Term Outcomes

Since 1989 all patients with anomalous origin of the left coronary artery from the pulmonary artery at our institution have been treated with aortic implantation. The purpose of this review was to assess the late outcomes of these patients, especially regarding left ventricular (LV) function and mitral valve insufficiency. Between 1989 and 2014, 36 patients had aortic implantation of anomalous origin of the left coronary artery from the pulmonary artery. Mean age at surgery was 2.5 ± 5.1 years (median, 0.5 years). Operative strategy included antegrade cold-blood cardioplegia, main pulmonary artery transection, aortic implantation with a large button of pulmonary artery, pulmonary reconstruction with fresh autologous pericardium, and prolonged postoperative inotropic and ventilator support. Mitral regurgitation and LV dysfunction were graded as 0 to 4 (0 = none, 1 = trivial, 1.5 = trivial-mild, 2 = mild, 2.5 = mild-moderate, 3 = moderate, 3.5 = moderate-severe, and 4 = severe). Mean mitral regurgitation grade preoperatively was 2.95 ± 0.95. Mean LV dysfunction grade was 3.14 ± 1.27. Mean cross-clamp and cardiopulmonary bypass times were 49.1 ± 18 minutes (median, 48.5 minutes) and 147.5 ± 45 minutes (median, 139 minutes), respectively. There was no operative or late mortality. Four patients had delayed sternal closure. Mean duration of ventilator support was 11 ± 6.6 days (median, 9 days). Two patients required 3 and 6 days of postoperative extracorporeal mechanical circulatory support. Mean length of stay was 25 ± 18 days (median, 19 days). No patient has required reoperation for supravalvar pulmonary stenosis, coronary stenosis, or mitral valve repair or replacement. Late echocardiographic follow-up shows a mean mitral regurgitation grade of 1.67 ± 1.05 and a mean LV dysfunction grade of 0.23 ± 0.68. Aortic implantation is our procedure of choice for patients with anomalous origin of the left coronary artery from the pulmonary artery. No patient required mitral valve repair or transplant. There was marked improvement of mitral regurgitation grade, return to essentially normal LV function, and no mortality during a 25-year period.

Most Important Outcomes Research Papers on Valvular Heart Disease

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Reviews. This series will summarize the most important manuscripts, as selected by the Editor, which have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes as well as general cardiology audience. The studies included in this article represent the most significant research in the area of valvular heart disease. ( Circ Cardiovasc Quality and Outcomes . 2012;5:-e103.) In recent years, no field of clinical cardiology has experienced a great influx of transformational therapeutic options as has the area of valvular heart disease. Treatment of severe aortic stenosis (AS) has been revolutionized by transcatheter aortic valve replacement (TAVR), which has been shown to improve life expectancy and functional outcomes in patients with inoperable AS1,2 and to have short-term outcomes comparable to surgical aortic valve replacement (AVR) in patients at high perioperative risk.3,4 Analogously, mitral valve disease has been amenable to percutaneous valve replacement,5,6 as well as clipping procedures7 that can substantively reduce severe mitral regurgitation (MR) and improve functional outcomes. Even right-sided heart disease involving valves in pulmonary8,9 and tricuspid10 positions has been treated successfully with endovascular techniques. Yet, even with this growing focus on percutaneous valvular interventions, open surgical techniques remain the dominant treatment strategies and standard of care for most advanced lesions. Surgical valve repair and replacement account for 10% to 20% of all cardiac surgical procedures,11–13 approximately two thirds of which are for AS.11–13 For patients undergoing surgery, there remains considerable debate about risk stratification,14 intraoperative technique,15 and postoperative …

David valve-sparing aortic root replacement: Equivalent mid-term outcome for different valve types with or without connective tissue disorder

Although implicitly accepted by many that the durability of valve-sparing aortic root replacement in patients with bicuspid aortic valve disease and connective tissue disorders will be inferior, this hypothesis has not been rigorously investigated. From 1993 to 2009, 233 patients (27% bicuspid aortic valve, 40% Marfan syndrome) underwent Tirone David valve-sparing aortic root replacement. Follow-up averaged 4.7 ± 3.3 years (1102 patient-years). Freedom from adverse outcomes was determined using log-rank calculations. Survival at 5 and 10 years was 98.7% ± 0.7% and 93.5% ± 5.1%, respectively. Freedom from reoperation (all causes) on the aortic root was 92.2% ± 3.6% at 10 years; 3 reoperations were aortic valve replacement owing to structural valve deterioration. Freedom from structural valve deterioration at 10 years was 96.1% ± 2.1%. No significant differences were found in survival (P=.805, P=.793, respectively), reoperation (P=.179, P=.973, respectively), structural valve deterioration (P=.639, P=.982, respectively), or any other functional or clinical endpoints when patients were stratified by valve type (tricuspid aortic valve vs bicuspid aortic valve) or associated connective tissue disorder. At the latest echocardiographic follow-up (95% complete), 202 patients (94.8%) had none or trace aortic regurgitation, 10 (4.7%) mild, 0 had moderate to severe, and 1 (0.5%) had severe aortic regurgitation. Freedom from greater than 2+ aortic regurgitation at 10 years was 95.3% ± 2.5%. Six patients sustained acute type B aortic dissection (freedom at 10 years, 90.4% ± 5.0%). Tirone David reimplantation valve-sparing aortic root replacement in carefully selected young patients was associated with excellent clinical and echocardiographic outcome in patients with either a tricuspid aortic valve or bicuspid aortic valve. No demonstrable adverse influence was found for Marfan syndrome or connective tissue disorder on durability, clinical outcome, or echocardiographic results.

The importance of neo-aortic root geometry in the arterial switch operation with the trap-door technique in the subsequent development of aortic valve regurgitation

Regarding neo-aortic valve regurgitation (neo-AR) after the arterial switch operation (ASO), the 'trap-door' technique was supposed to be a risk factor due to a distortion of the sinotubular junction (STJ) geometry. Here we report our results of the 'trap-door' technique with a special emphasis on root geometry including the ratio of STJ to annulus. From August 1991 to March 2010, 240 patients with transposition of the great arteries underwent the ASO and who had at least 1 year of follow-up were included in this study. The medical records were retrospectively reviewed. The median age and body weight at the time of operation were 11 (0-1213) days and 3.4 (1.30-18.75) kg, respectively. The median follow-up duration was 79 months (range 12 months-19.5 years). At the latest echocardiographic follow-up, only six patients had neo-AR greater than Grade II (6 of 240, 2.5%). We found no relationship between neo-AR greater than Grade II and perioperative factors. The actual sizes of the neo-aortic annulus, mid-sinus and STJ were observed as having increased over time. However, most z-scores of STJ at the latest echocardiography varied between -2 and 2 and, more importantly, the ratio of STJ to neo-aortic annulus was 0.93 ± 0.20, which was near normal at the latest echocardiographic follow-up. Our results showed a very low incidence of significant neo-AR, which was relatively attributable to the preserved z-score of STJ and the normal range of STJ/annulus ratio. Therefore, we propose that it is important to maintain these factors adequately during the reconstruction of the neo-aortic root in the ASO.

Long-Term Results of 203 Young and Middle-Aged Patients With More Than 10 Years of Follow-Up After the Original Subcoronary Ross Operation

The choice of prosthesis for aortic valve replacement in young and middle-aged patients remains challenging owing to the accelerated degeneration of bioprostheses in these age groups and the risks of thromboembolism and bleeding with mechanical valves. Theoretically, the living pulmonary autograft (Ross operation) would be advantageous. Long-term results of the various Ross techniques are needed for defining the value of this surgical concept. Of a total of 576 subcoronary Ross patients operated on between June 1994 and June 2011, we report on 203 consecutive subcoronary patients (mean age, 47.2±13.6 years, 155 male, 2,491 patient-years) with a follow-up of at least 10 years (mean, 12.3±2.9 years). Early and late mortality were 0.98% (n=2) and 11.4% (n=23). Valve-related mortality was 2.5% (n=5). Survival did not differ from that of the general German population. Freedom from autograft or allograft reoperation was 92.2% at 10 years and 87.1% at 15 years. Five major bleeding (0.20%/patient-year) and 11 thromboembolic events (0.44%/patient-year) occurred in 5 and 10 patients, respectively. Neither a systematic increase in aortic regurgitation nor an increase in root dimensions with time could be observed. In the vast majority of patients, valvular hemodynamics at latest echocardiographic follow-up were excellent. Long-term results of the original subcoronary Ross operation reveal normal survival, excellent hemodynamics, low risk of thromboembolism or bleeding, and small risk for reoperation. These results favor the pulmonary autograft concept in young and middle-aged patients in experienced centers and may serve to better define its role in surgical treatment of aortic valve disease in these patients.

Are stentless valves hemodynamically superior to stented valves? Long-term follow-up of a randomized trial comparing Carpentier–Edwards pericardial valve with the Toronto Stentless Porcine Valve

The benefit of stentless valves remains in question. In 1999, a randomized trial comparing stentless and stented valves was unable to demonstrate any hemodynamic or clinical benefits at 1 year after implantation. This study reviews long-term outcomes of patients randomized in the aforementioned trial. Between 1996 and 1999, 99 patients undergoing aortic valve replacement were randomized to receive either a stented Carpentier-Edwards pericardial valve (CE) (Edwards Lifesciences, Irvine, Calif) or a Toronto Stentless Porcine Valve (SPV) (St Jude Medical, Minneapolis, Minn). Among these, 38 patients were available for late echocardiographic follow-up (CE, n = 17; SPV, n = 21). Echocardiographic analysis was undertaken both at rest and with dobutamine stress, and functional status (Duke Activity Status Index) was compared at a mean of 9.3 years postoperatively (range, 7.5-11.1 years). Clinical follow-up was 82% complete at a mean of 10.3 years postoperatively (range, 7.5-12.2 years). Preoperative characteristics were similar between groups. Effective orifice areas increased in both groups over time. Although there were no differences in effective orifice areas at 1 year, at 9 years, effective orifice areas were significantly greater in the SPV group (CE, 1.49 +/- 0.59 cm(2); SPV, 2.00 +/- 0.53 cm(2); P = .011). Similarly, mean and peak gradients decreased in both groups over time; however, at 9 years, gradients were lower in the SPV group (mean: CE, 10.8 +/- 3.8 mm Hg; SPV, 7.8 +/- 4.8 mm Hg; P = .011; peak: CE, 20.4 +/- 6.5 mm Hg; SPV, 14.6 +/- 7.1 mm Hg; P = .022). Such differences were magnified with dobutamine stress (mean: CE, 22.7 +/- 6.1 mm Hg; SPV, 15.3 +/- 8.4 mm Hg; P = .008; peak: CE, 48.1 +/- 11.8 mm Hg; SPV, 30.8 +/- 17.7 mm Hg; P = .001). Ventricular mass regression occurred in both groups; however, no differences were demonstrated between groups either on echocardiographic, magnetic resonance imaging, or biochemical (plasma B-type [brain] natriuretic peptide) assessment (P = .74). Similarly, Duke Activity Status Index scores of functional status improved in both groups over time; however, no differences were noted between groups (CE, 27.5 +/- 19.1; SPV, 19.9 +/- 12.0; P = .69). Freedom from reoperation at 12 years was 92% +/- 5% in patients with CEs and 75% +/- 5% in patients with SPVs (P = .65). Freedom from valve-related morbidity at 12 years was 82% +/- 7% in patients with CEs and 55% +/- 7% in patients with SPVs (P = .05). Finally, 12-year actuarial survival was 35% +/- 7% in patients with CEs and 52% +/- 7% in patients with SPVs (P = .37). Although offering improved hemodynamic outcomes, the SPV did not afford superior mass regression or improved clinical outcomes up to 12 years after implantation.

Long‐term follow‐up of the STARFlex® device for closure of secundum atrial septal defect

There is limited published outcome data on the STARFlex device for transcatheter closure of atrial septal defects (ASD). To contribute to the long term outcomes of ASD device closure with the STARFlex device. Results of a prospective FDA approved clinical trial (1999-2001) from a single institution of the STARFlex device for simple ASD was reviewed. The inclusion criteria included age >or=2 years, isolated secundum ASD, evidence of right ventricular volume overload, and maximum stretched diameter <22 mm. A retrospective review of the original study data with most recent follow-up was performed. Clinical success in the trial was defined as complete closure or residual leak <or=2 mm, absence of a severe complication and no need for an additional device or surgery to treat the ASD. Twenty seven (27) patients were prospectively enrolled in the study period with a procedural success in 23 (85%). There were two severe complications, both 40 mm device embolizations that underwent semiurgent surgical intervention for device removal and ASD closure (40 mm device subsequently withdrawn from trial). Device placement was unsuccessful in two patients due to malposition related to an insufficient retro-aortic rim, with elective surgical closure. Unsuccessful procedural outcomes were statistically associated with deficient rims (P < 0.01). Of the 23 long term follow-up device patients, 23 (100%) achieved clinical success: 22 (96%) had complete closure at 1 year and latest echocardiographic follow-up and one case had a small <2 mm residual defect that has persisted. There have been no late complications with normalization of RV volumes in 92% and no deleterious ECG changes. Device fractures occurred in 8/23 (35%) devices and were more common in the larger devices (P < 0.05) but had no sequelae. None required any further intervention to treat the ASD and there were no infectious or thrombotic issues. In this cohort the STARFlex device for secundum ASD closure provided procedural success in 85% with failures due to surgical referral. All 23 patients with a STARFlex device with available long term follow-up had clinical success. Further long term data is required.

Magnetic resonance imaging assessment of reverse left ventricular remodeling late after restrictive mitral annuloplasty in early stages of dilated cardiomyopathy

Magnetic resonance imaging was used to evaluate left ventricular reverse remodeling at long-term follow-up (3-4 years) after restrictive mitral annuloplasty in patients with early stages of nonischemic, dilated cardiomyopathy, and severe mitral regurgitation. Twenty-two selected patients (eligible to undergo magnetic resonance imaging) with mild to moderate heart failure (mean New York Heart Association class 2.2 +/- 0.4), dilated cardiomyopathy (left ventricular ejection fraction 37% +/- 5%, left ventricular end-diastolic volume 215 +/- 34 mL), and severe mitral regurgitation (grade 3-4+) underwent restrictive mitral annuloplasty. Magnetic resonance imaging was performed 1 week before surgery and repeated after 3 to 4 years. There was no hospital mortality or major morbidity. Two patients died during follow-up (9%), and 2 patients could not undergo repeat magnetic resonance imaging because of comorbidity. New York Heart Association class improved from 2.2 +/- 0.4 to 1.2 +/- 0.4 (P < .05). Mitral regurgitation was minimal at late echocardiographic follow-up. There were significant decreases in indexed (to body surface area) left atrial end-systolic volume (from 84 +/- 20 mL/m(2) to 68 +/- 12 mL/m(2), P < .01), left ventricular end-systolic volume (from 42 +/- 14 mL/m(2) to 31 +/- 12 mL/m(2), P < .01), left ventricular end-diastolic volume (from 110 +/- 18 mL/m(2) to 80 +/- 17 mL/m(2), P < .01), and left ventricular mass (from 76 +/- 21 g/m(2) to 66 +/- 12 g/m(2), P = .03). Forward left ventricular ejection fraction improved from 37% +/- 5% to 55% +/- 10% (P < .01). Indexed left atrial end-diastolic volume did not show a significant decrease (from 48 +/- 16 mL/m(2) to 44 +/- 10 mL/m(2), P = .15). Magnetic resonance imaging confirms sustained significant reverse left atrial and ventricular remodeling at late (3-4 years) follow-up in patients with nonischemic, dilated cardiomyopathy, and mild to moderate heart failure after restrictive mitral annuloplasty.

Aortopulmonary Window and Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery: Long-Term Result After Takeuchi-Type Repair

We describe the case of a 2-month-old infant with the rare association of aortopulmonary window and anomalous origin of the right coronary artery from the pulmonary artery. The diagnosis was made by angiography and surgical repair was carried on employing the Takeuchi procedure. The angiographic control obtained 5 years after the operation showed an optimal surgical result. The latest echocardiographic follow-up, 24 years after the repair, has been fully satisfactory.

Tricuspid valve reconstruction, a treatment option in acute endocarditis.

Tricuspid valve endocardititis is treated surgically by total valve excision or valve replacement. Both procedures are controversial with regard to the hemodynamic consequences and to the long-term prognosis. In the following, results of tricuspid valve repair in acute infective endocarditis are reported and discussed as an additional treatment option. Between January 1988 and December 1993, 118 patients were operated on for acute valve endocarditis at our institution. Eleven of these patients had tricuspid valve endocarditis, isolated (n = 7) or combined with endocarditis of a left-sided valve (n = 4). In the cases with isolated tricuspid valve endocarditis, the indication for surgery was intractable infection in six and hemodynamically relevant tricuspid insufficiency in one out of seven patients. In all patients with associated left-sided endocarditis, the indication was hemodynamic deterioration. In eight patients the tricuspid valve endocarditis was treated as follows: debridement, vegectomy, patch reconstruction of the cusps, reducing the cusps to two. In three patients reconstruction was not possible because of extensive involvement of all parts of the valve, including the valve ring and the papillary muscles. In these patients primary valve replacement (n = 1) or valve excision with secondary replacement (n = 2) was performed. In four patients tricuspid reconstruction was combined with mitral (n = 1), aortic (n = 1) or double valve replacement (n = 2). Postoperatively, signs of infection vanished in all surviving patients (n = 10) and tricuspid valve endocarditis healed without recurrences. Implanted prosthetic material did not lead to recurrent infection. One patient died early postoperatively after valve excision, in septic shock and multi-organ failure. In seven patients late echocardiographic follow-up showed tricuspid regurgitation grade 0 in three patients, I in two, II in one and III in one. Our results suggest that valve repair is a reasonable treatment option for tricuspid valve endocarditis in all cases with localized infection of the valve. Only if extensive valve destruction excludes valve repair, would we now favor primary valve replacement over simple valvulectomy. In all other cases primary valve reconstruction is the treatment of choice for tricuspid valve endocarditis, if surgery is indicated.

Secundum atrial septal defect repair: long-term surgical outcome and the problem of late mitral regurgitation.

This study examines the clinical and surgical outcome of a group of 55 patients (mean age 33 years) with secundum atrial septal defect who underwent surgical repair of this defect between 1981 and 1990. A group of 25 of these patients underwent late echocardiographic follow-up. Fifty-two patients underwent repair by direct suturing and three by patch closure. Surgical mortality was nil. There was one late death of a 58 year old who died from cardiac failure 4 years after surgery. Late postoperative morbidity consisted of two patients; one, age 63 at the time of surgery, required mitral and tricuspid valve replacement 6 years later and one, age 77 at surgery, developed cardiac failure 3 years later. Atrial fibrillation persisted in the six patients who had the rhythm before surgery and developed postoperatively in two patients aged 54 and 58. Two patients aged 49 and 57 developed immediate postoperative sinus node dysfunction requiring permanent pacing. The mean age at surgery of those six patients who suffered cardiac morbidity was 60 years. The patients with preoperative angiographic evidence of mitral valve prolapse were significantly older (P < 0.001) and had higher mean pulmonary artery pressures (P < 0.001) than patients with normal valves. There was no significant relationship between shunt size and mitral valve prolapse. Echocardiographic follow-up showed persistent mitral valve prolapse in all nine patients who developed the condition preoperatively. Five patients developed mitral valve prolapse with mitral regurgitation postoperatively, one of whom needed subsequent mitral and tricuspid valve replacement. These five patient were on average older (mean age 54) but the group was too small to prove significance. The follow-up data illustrate the current low mortality and morbidity associated with surgical closure of atrial septal defects. Late postoperative echocardiography had revealed not only that mitral valve prolapse persists in those patients who developed the condition pre-operatively but that new cases of mitral valve prolapse with mitral regurgitation can occur after atrial septal defect closure.