Risk Factors For Reoperation Research Articles

Abstract 17048: Fifteen Year Follow-Up After Aortic Root Replacement with Stentless Biological Valve Conduits: Homograft versus Freestyle

Objectives: The choice of biologic aortic valve substitute for aortic root replacement is multifaceted. Herein, we report the compared long-term outcome of two type of stentless biologic valve conduits namely homograft and Fresstyle bioprosthesis used to replace the aortic root and followed prospectively up to 15 years. Methods: Between 1993 and 2011, 188 patients underwent elective primary aortic root replacement with a stentless bioprosthetic aortic valve with (n=38) or without (n=150) CABG. Among these patients, 98 Freestyle and 90 homografts were implanted. All clinical and echocardioraphic data were collected prospectively. Mean overall follow-up was 8.5±3.9 years (range: 0.1-15). It was 8.4±3.8 years for Freestyle, and 8.5±4.0 years for homografts, and complete in all patients. Results: Patient characteristics were comparable between groups except for age and number of pre-operative diagnosis of endocarditis ( p <0.0001) and moderate/severe aortic insufficiency ( p <0.008). The mean age was significantly higher in the Freesstyle (65.4±8.5years) compared to homograft (48.1±13.0 years) group ( p < 0.0001). Hospital mortality was comparable between the Freestyle and the homograft group (5.1% versus 7.8%, p =0.6). Ten and 15-years survival was 66.7% and 53.0% in the Freestyle versus 89.9% and 69.1% in the homograft group, respectively ( p <0.001). Freedom from reoperation due to structural valve deterioration (SVD) at 10 and 15 years was 98.8% and.92.7% for the Freestyle compared to 87.4% and 68.6% in the homografts group, respectively ( p =0.009). Independent risk factors for reoperation for SVD were age (OR:1.1, CI: 1.02-1.1, p =0.002), and use of homograft (OR:7.7, CI: 1.7-35.5, p =0.008). Independent risk factors for poorer long-term survival were age (OR 1.2, CI: 1.1-1.3, p =0.001), and lenght of hospital stay (OR 2.9, CI: 1.5-3.8, p =0.0003). Mean pressure gradient at the end of follow-up was 8.5±6.2 mm Hg for the Freestyle and 9.9±9.1 mm Hg for the homograft patients. Conclusion: The choice of stentless biologic valve for aortic root reconstruction have no influence on early and long-term survival. The use of biologic root reconstruction with Freestyle bioprostheses provides a better freedom from reoperation due to SVD compared to homografts.

Midterm Outcome of Valve-Sparing Aortic Root Replacement in Inherited Connective Tissue Disorders

This study determined the midterm outcome of valve-sparing aortic root replacement for patients with inherited connective tissue disorders. From 1993 to 2008, 94 patients underwent valve-sparing aortic root replacement. Sixty patients (64%), average age 33 years (range, 15 to 61 years), had inherited connective tissue disorders: Marfan syndrome, 54 (92%); Loeys-Dietz syndrome, 5 (8%); and smooth muscle α-actin (ACTA2) mutation in 1. Median preoperative sinus diameter was 52 mm (range, 42 to 76 mm), and moderate/severe aortic regurgitation was present in 14 (23%). Seven (12%, 1993 to 1999) underwent remodeling procedures, and 53 had reimplantation procedures. Cusp repair was performed in 4. Median follow-up was 55 months (range, 1 to 149 months). There were 15 patients in the early term (1993 to 2000) and 45 in the late term (2001 to 2008). Four late deaths occurred (cardiac, 3; aortic, 1), with 10-year survival of 86%. Rates of freedom from aortic valve replacement at 5 and 10 years were 85% and 58% in remodeling and 96% and 58% in reimplantation. Risk factors for reoperations were postprocedure intraoperative aortic insufficiency greater than mild (p = 0.046), remodeling procedure (p = 0.016), and early term (p = 0.0002). One patient (2%) with none/trivial postprocedure aortic insufficiency required aortic valve replacement. Freedom from reoperation in patients with none/trivial postprocedure aortic insufficiency at 5 and 10 years was 100% and 67%. Meticulous control of aortic insufficiency during operation would bring favorable midterm durability in valve-sparing aortic root replacement using a reimplantation technique, even in patients with inherited connective tissue disorders.

Risk of recurrence after surgery for chronic radiation enteritis

Approximately one-third of patients with chronic radiation enteritis (CRE) require surgery, which is associated with a high morbidity rate and a high risk of reoperation. The aim of this study was to report outcome after surgery for CRE. Patients with CRE who underwent operation with extensive small bowel resection between 1980 and 2009 were included in the study. Postoperative morbidity and mortality, reoperation for recurrent enteritis and risk factors for reoperation were analysed. Of 107 patients (94 women; 87·8 per cent) with CRE included in the study, the main indication for surgery was symptomatic stricture (82 patients; 76·6 per cent). Forty-nine ileocaecal resections (45·8 per cent) were performed. Overall and surgical morbidity rates were 74·8 per cent (80 patients) and 28·0 per cent (30) respectively. Fourteen patients (13·1 per cent) underwent reoperation for complications. Reoperation rates for CRE at 1 and 3 years of follow-up were 37 and 54 per cent respectively. Risk factors for reoperation for recurrent enteritis were: emergency surgery (odds ratio (OR) 2·72, 95 per cent confidence interval 1·57 to 4·86), anastomotic leakage (OR 2·53, 1·54 to 4·42) and male sex (OR 3·57, 1·82 to 7·29). The only protective factor for reoperation was ileocaecal resection during the first surgical procedure (OR 4·48, 2·52 to 8·31). Ileocaecal resection was the only factor that protected against reoperation for recurrent CRE, demonstrating the importance of resecting all damaged tissue in these patients. These results suggest that there is little place for intestinal bypass surgery or adhesiolysis.

Thirty-Year Experience With the Arterial Switch Operation

We evaluated the results of the arterial switch operation (ASO) being performed at our institution for more than 30 years and identified risk factors for mortality and reoperation. Clinical outcome of 332 consecutive patients with transposition of the great arteries undergoing ASO was retrospectively analyzed, using surgical reports, medical charts, and latest follow-up echocardiography. Statistical analysis was performed using the Kaplan-Meier method and univariable and multivariable binary logistic and Cox regression analyses. In-hospital mortality was 11.4%. At 15 years, estimated overall survival was 85.2%, and estimated freedom from reoperation was 74.0%. Cross-clamp time (p=0.001) and absence of the Lecompte maneuver (p=0.001) were identified as independent risk factors for in-hospital mortality, whereas coronary problems during surgery (p=0.009) and postoperative pacemaker implantation (p<0.001) were independent risk factors for late mortality. Independent risk factors for reoperation were higher age at the time of the ASO (p=0.002), presence of arch abnormalities (p<0.001), coronary problems during surgery (p=0.005), and duration of ventilation (p<0.001). At latest echocardiography, moderate or severe neoaortic regurgitation was present in 3.4% of the patients. Overall, 30 years of experience with the ASO shows good survival and event-free survival rates. Coronary transfer problems during surgery were found to be an important risk factor for late mortality and reoperation. However, coronary anatomy other than 1LCx-2R and an intramural course of the left coronary artery or left anterior descending artery were not risk factors for mortality or reoperation. Neoaortic regurgitation does not seem to form a major problem.

Incidence and risk factors for reoperation of surgically treated pelvic organ prolapse

The objective of our study was to estimate the incidence and to identify the risk factors for reoperation of surgically treated pelvic organ prolapse (POP). We conducted a nested case-control study among 1,811 women who underwent POP surgery from January 1988 to June 2007. Cases (n = 102) were women who required reoperation for POP following the first intervention through December 2008. Controls (n = 226) were women randomly selected from the same cohort who did not require reoperation. The incidence of POP reoperation was 5.1 per 1,000 women-years. The cumulative incidence was 5.6%. Risk factors included preoperative prolapse in more than two vaginal compartments (adjusted OR 5.2; 95% CI 2.8-9.7), history of surgery for POP and/or urinary incontinence (adjusted OR 3.2; 95% CI 1.5-7.1), and sexual activity (adjusted OR 2.0; 95% CI 1.0-3.7). The risk of POP reoperation is relatively low and is associated with preexisting weakness of pelvic tissues.

Morbidity of Bleeding After Cardiac Surgery: Is It Blood Transfusion, Reoperation for Bleeding, or Both?

Etiology for increased morbidity in patients (2% to 8%) undergoing reoperation for bleeding after cardiac surgery is unclear. Recent work suggests that it may be related to red-cell transfusion, but what role does reoperation itself play? We sought to determine prevalence of and risk factors for reoperation for bleeding, separate the effect of reoperation from that of transfusion on hospital mortality and major morbidity, and identify the source of bleeding. From January 1, 2000 to January 1, 2010, 18,891 primary and repeat coronary artery bypass grafting, valve, or combined operations were performed. Risk factors for reoperation were identified by multivariable logistic regression. Hospital mortality and major morbidity were compared in propensity-matched patients requiring reoperation and not. Medical records from 2005 to 2010 were reviewed to determine bleeding source. A total of 566 patients (3.0%) underwent reoperation for bleeding, with considerable variability over time. Risk factors included older age, higher acuity, greater comorbidity, aortic valve surgery, longer myocardial ischemic and cardiopulmonary bypass durations, and surgeon. Mortality was higher for propensity-matched patients requiring reoperation; 8.5% (68% confidence interval [CI] 7.3% to 9.9%) versus 1.8% (CI 1.2% to 2.5%). Both greater transfusion and reoperation were independently associated with increased risk of mortality and major morbidity. At reoperation, technical factors (74%), coagulopathy (13%), both (10%), or other (3.3%) causes were responsible for bleeding. Transfusion and reoperation for bleeding both contribute to postoperative mortality and morbidity. Technical reasons are at the root of most bleeding, emphasizing a major focus for process improvement to minimize need for reoperation and blood use.

Long Term Results of Right Ventricular Outflow Tract Reconstruction with Homografts

BackgroundHomograft cardiac valves and valved-conduits have been available in our institute since 1992. We sought to determine the long-term outcome after right ventricular outflow tract (RVOT) reconstruction using homografts, and risk factors for reoperation were analyzed.Materials and MethodsWe retrospectively reviewed 112 patients who had undergone repair using 116 homografts between 1992 and 2008. Median age and body weight at operation were 31.2 months and 12.2 kg, respectively. The diagnoses were pulmonary atresia or stenosis with ventricular septal defect (n=93), congenital aortic valve diseases (n=15), and truncus arteriosus (N=8). Mean follow-up duration was 79.2±14.8 months.ResultsThere were 10 early and 4 late deaths. Overall survival rate was 89.6%, 88.7%, 86.1% at postoperative 1 year, 5 years and 10 years, respectively. Body weight at operation, cardiopulmonary bypass (CPB) time and aortic cross-clamping (ACC) time were identified as risk factors for death. Forty-three reoperations were performed in thirty-nine patients. Freedom from reoperation was 97.0%, 77.8%, 35.0% at postoperative 1 year, 5 years and 10 years respectively. Small-sized graft was identified as a risk factor for reoperation.ConclusionAlthough long-term survival after RVOT reconstruction with homografts was excellent, freedom from reoperation was unsatisfactory, especially in patients who had small grafts upon initial repair. Thus, alternative surgical strategies not using small grafts may need to be considered in this subset.

A modular cementless stem vs. cemented long-stem prostheses in revision surgery of the hip

Background and purpose Modular cementless revision prostheses are being used with increasing frequency. In this paper, we review risk factors for the outcome of the Link MP stem and report implant survival compared to conventional cemented long-stem hip revision arthroplasties.Patients and methods We used data recorded in the Swedish Hip Arthroplasty Register. 812 consecutive revisions with the MP stem (mean follow-up time 3.4 years) and a control group with 1,073 cemented long stems (mean follow-up time 4.2 years) were included. Kaplan-Meier analysis was used to determine implant survival. The Cox regression model was used to study risk factors for reoperation and revision.Results The mean age at revision surgery for the MP stem was 72 (SD 11) years. Decreasing age (HR = 1.1, 95% CI: 1–1.1), multiple previous revisions (HR = 2.6, 95% CI: 1.1–6.2), short stem length (HR = 2.4, 95% CI: 1.1–5.2), standard neck offset (HR = 5, 95% CI: 1.5–17) and short head-neck length (HR = 5.3, 95% CI 1.4–21) were risk factors for reoperation. There was an overall increased risk of reoperation (HR = 1.7, 95% CI: 1.3–2.4) and revision (HR = 1.9, 95% CI: 1.2–3.1) for the MP prostheses compared to the controls.Interpretation The cumulative survival with both reoperation and revision as the endpoint was better for the cemented stems with up to 3 years of follow-up. Thereafter, the survival curves converged, mainly because of increasing incidence of revision due to loosening in the cemented group. We recommend the use of cemented long stems in patients with limited bone loss and in older patients.

Age Less Than Two Years Is Not a Risk Factor for Mortality After Mitral Valve Replacement in Children

Outcomes for mitral valve replacement (MVR) in the pediatric population are generally reported as poor, particularly in patients less than 2 years old. We compared long-term morbidity and mortality associated with MVR between patients less than 2 years old and patients 2 to 18 years old. We evaluated pediatric patients undergoing MVR from March 1990 to November 2007 at our institution. Morbidity and mortality was compared between patients less than 2 years and patients 2 to 18 years old. Primary endpoints measured were postoperative survival, long-term survival, reoperation, cerebrovascular accident or transient ischemic attack, and significant bleeding events. Forty-five patients underwent 54 MVRs. Median age was 3.1 years; 18 patients were under 2 years. Median follow-up time was 5.4 years. There was no statistically significant difference between long-term or short-term survival between the two age groups, with 30-day survival of 89% (younger patients) versus 100% (older patients), and 10-year survival of 82% (younger patients) versus 85% (older patients). Freedom from reoperation for the younger age group was 40% at 10 years versus 96% for the older patients, p = 0.003. In our population, there was no statistically significant difference in survival between patients less than 2 years and patients 2 to 18 years. In children undergoing MVR, age less than 2 years remains a risk factor for reoperation but not for mortality.

Midterm Results of Aortic Valve Replacement Using Tissue Valve

Dukhwan Moon, M.D.*, Jae-Won Lee, M.D.*, Yun Seok Kim, M.D.**, Won-Chul Cho, M.D.*, Sung-Ho Jung, M.D.*, Suk-Jung Choo, M.D.*, Cheol-Hyun Chung, M.D.*. Korean J Thorac Cardiovasc Surg 2010;43:627-34. https://doi.org/10.5090/kjtcs.2010.43.6.627

Unicompartmental knee arthroplasties implanted for osteoarthritis with partial loss of joint space have high re-operation rates

The indications and contraindications for unicompartmental knee arthroplasty (UKA) are controversial. The aim of the study was to determine the risk factors for re-operation in our practice. A series of 113 medial UKAs with mean follow-up of 63 months were reviewed retrospectively. Pre-operatively all knees had radiographic or arthroscopic evidence of severe cartilage damage. The re-operation rate was not related to age, gender, arthroscopic finding or body mass index. It was related to the joint space on pre-operative standing weight bearing radiographs taken in extension. The re-operation rate was 6 (95% CI 2.1–17, P < 0.001) times higher when the thickness of the pre-operative medial joint space was > 2 mm rather than ≤ 2 mm. It was 8 (95% CI 2.8–22.5, P < 0.001) times higher when the thickness of the pre-operative medial space was > 40% of the thickness of the lateral space. The ratio of pre-operative joint spaces has a greater influence on revision rate than the absolute measurement and is independent of radiographic magnification or the patient's normal cartilage thickness. We therefore recommend that, in medial knee osteoarthritis, UKA should only be used if the pre-operative medial joint space on standing radiographs is ≤ 40% of the lateral joint space, even if severe cartilage damage is seen arthroscopically.

Risk Factors for Re-operation Following Tubularized Incised Plate Urethroplasty: A Comprehensive Analysis

To review our 10-year experience with tubularized incised-plate (TIP) urethroplasty and determine the risk factors for reoperation. The hospital records of 391 patients underwent the TIP procedure from April 1997 to September 2007 were reviewed retrospectively. Data were collected with respect to patient demographics, characteristics of the hypospadias malformation, intraoperative factors and postoperative outcome. Complications requiring reoperation were identified. Univariate and multivariate analyses were used to identify risk factors for reoperation. Median age at surgery was 2 years (range, 0.5-16). Median follow-up was 11 months (range, 3-96). Neourethral complications requiring re-operation developed in 48 patients. A total of 52 reoperations were required because of fistulae (25/6%), neourethral disruption (13/3%), meatal stenosis (13/3%), and stricture (1/0.3%). The re-operation rate was significantly higher in the presence of interrupted sutures, chordee requiring dorsal plication, penoscrotal or proximal shaft defects, a lack of neourethral vascular tissue coverage, and in children over 4 years of age. Multivariate analysis identified the last 3 of these variables as independent risk factors for reoperation. In addition to position of the urethral meatus and the absence of vascular covering flaps, we found that an age over 4 years at the time of surgery is an additional independent risk factor for neourethral complications requiring reoperation.

Survivorship analysis of 150 consecutive patients with DIAM™ implantation for surgery of lumbar spinal stenosis and disc herniation

Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1-48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4-5; 31, L5-6) and 4 two-level (L4-5 and L5-6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5-6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan-Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2-29 months). Kaplan-Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5-6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4-5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5-6 [hazard ratio (HR), 10.3; 95% CI, 1.7-63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2-90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5-6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4-5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5-6 and two-level in patients with LSTV are significant risk factors for reoperation.

Atrioventricular valve repair in patients with functional single ventricle

We aimed to evaluate surgical repair of atrioventricular valve regurgitation in patients with functional single ventricle. The medical records of 65 consecutive patients with functional single ventricle who underwent atrioventricular valve repair between January 1999 and October 2008 were reviewed retrospectively. Their characteristics were as follows: median age, 9.5 months; median weight, 6.0 kg; atrial isomerism, 31 patients; and hypoplastic left heart syndrome, 12 patients. Regurgitation was repaired at the palliative, Glenn, and Fontan stage in 21, 29, and 15 patients, respectively. The overall survival was 79% and 70% at 1 and 5 years, respectively. The risk factors for mortality were age less than 3 months (P < .001), body weight less than 4 kg (P < .001), hypoplastic left heart syndrome (P = .001), concomitant Norwood (P < .001), and the palliative stage (P = .004) on the univariate analysis, and body weight less than 4 kg (P = .010, hazard ratio, 9.8; 95% confidence interval, 1.7-55.6) on the multivariate analysis. Twenty patients underwent reoperation (repairs in 15; replacements in 5), and freedom from reoperation at 1 and 5 years was 69% and 57%, respectively. Concomitant systemic-to-pulmonary shunt (P = .040) was a risk factor for reoperation on the univariate analysis. Of the 48 survivors, 38 underwent Fontan completion, 7 underwent the Glenn procedure, and 3 are awaiting the Glenn procedure. The midterm results of atrioventricular valve repair in patients with functional single ventricle were favorable; however, young and small patients, especially those with hypoplastic left heart syndrome, still had poor outcomes.

Extended Criteria Donor and Severe Intraoperative Glucose Variability: Association With Reoperation for Hemorrhage in Liver Transplantation

Reoperations for hemorrhage following liver transplantation (OLT) are commonly associated with increased morbidity and mortality. We sought to determine the incidence and risk factors for reoperation for hemorrhage among adult liver transplantations. We retrospectively analyzed 668 patients transplanted between January 2004 and November 2007. Within 30 days following transplantation one hundred eleven patients (16.6%) underwent 156 reoperations for hemorrhage, averaging 1.4 reoperations per patient. More than half of the reoperations occurred during the first 2 postoperative days. One-third of patients required 2 or more reoperations. Multivariate logistic regression analysis showed 4 independent risk factors: grafts from donors with multiple extended criteria, severe intraoperative glucose variability, intraoperative use of vasopressors, and red blood cell transfusion requirement. In conclusion, we identified several independent risk factors for reoperation due to hemorrhage following OLT. Avoidance of severe intraoperative glucose variability and careful evaluation of the benefits and risks of utilizing extended criteria donors must be considered before transplantation.

Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (SPR Study): Multiple-event analysis of risk factors for reoperations. SPR Study report no. 4

To identify risk factors that may lead to reoperations following primary vitrectomy (PV) and scleral buckling surgery (SB) for rhegmatogenous retinal detachment (RRD). Analysis of the association between distinct parameters and the necessity for reoperations in the 'Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study' (SPR Study) using an Andersen-Gill-mean intensity model. The risk for recurrent reoperations is significantly reduced by primary vitrectomy (PV) compared to scleral buckling (SB) in pseudophakic eyes (p = 0.0009) and increased after PV compared to SB in phakic eyes (p < 0.0001). Additional significant risk factors were in the pseudophakic group preoperative deterioration of visual acuity (p = 0.0226), YAG capsulotomy (p = 0.0043), large breaks (p = 0.0290), number of affected quadrants (p = 0.0387), retinal incarceration during surgery (p = 0.0115), number of breaks (p < 0.0001) and symptomatic visual field defect (p = 0.0463). In the phakic group, associated risk factors were low intraocular pressure (p = 0.0013) and persistent intraoperative detachment at the buckle (p = 0.0184). Reoperations are used as an indicator for the quality and efficacy of surgical techniques. Using a refined multivariate survival model, distinct factors were identified and associated with one or more reoperations after PV or SB in RRD surgery. This information should be useful in the decision process regarding the surgical approach.

Long-term results after mitral valve repair in children

We analysed the long-term results of mitral valve (MV) repair in children. We reviewed clinical records of 139 children (<18 years) who underwent MV repair between 1988 and 2007. Patients with atrioventricular septal defect, single ventricle or atrioventricular discordance were excluded. Median age was 2.3 years (2 months to 17.6 years), and 47 children (34%) were infants. Mitral regurgitation (MR) was predominant in 125 patients (90%), and 91 (73%) of these showed MR grade > or = 3. Mitral stenosis (MS) was predominant in 14 patients (10%), and median mean pressure gradient across the MV was 9.0 mmHg (0-20 mmHg). Associated cardiac lesions were present in 111 patients (80%) and were addressed concurrently in 105 patients. Various surgical techniques were used according to the functional and pathologic findings of MV. There was no early death. Median follow-up was 8 years (2 months to 20 years, 78% complete). Twenty-six patients required 29 MV re-operations, and 11 of these required MV replacements. At 15 years, freedom from MV re-operation and MV replacement was 77% and 90%, respectively. Diagnosis of MS and MV status on discharge (MR grade > or =3 or MS gradient > or =10 mmHg) were significant risk factors for re-operation. There were three late deaths, and the overall survival was 97% at 15 years. Among 122 survivors with MR, 102 patients (84%) underwent echocardiography during follow-up. The degree of MR decreased significantly and only five patients showed MR grade 3. Among 14 survivors with MS, eight patients (57%) underwent echocardiography during follow-up. The degree of MS decreased significantly and median MS gradient was 2.8 mmHg (0-10 mmHg). All survivors remain in the NYHA class I or II. MV repair in children showed excellent survival, acceptable re-operation rate and satisfactory valve function at long-term follow-up. Residual MV dysfunction was a significant risk factor for re-operation, but re-repair was successful in more than half of the patients who underwent re-operation.

CARD15 Gene Variants and Risk of Reoperation in Crohn's Disease Patients

Several studies have investigated, with conflicting results, the risk factors for reoperation in Crohn's disease (CD) patients. CARD15 gene variants have been identified as a major genetic risk factor for CD patients and associated with ileal disease, stenosis, and risk of surgery. However, data regarding the association between these variants and the need for reoperation are very few and conflicting. This study evaluated the risk factors of reoperation, including CARD15 gene variants. A total of 253 consecutive CD patients, recruited in four Italian tertiary-care inflammatory bowel disease (IBD) referral centers, who had submitted to surgery for CD, were included in the study. Clinical characteristics of CD patients, time and main indications for surgery, type of operation, postoperative therapy, and time to second surgery were recorded. CARD15 gene variants were determined by DNA sequencing analysis in each center. Factors related to surgical recurrence, including CARD15 variants, were estimated by Cox proportional hazard regression. In all, 89 patients (35.1%) showed at least one surgical recurrence. Reoperation was significantly correlated with stenosis as indications at initial surgery only. CARD15 variants were found in 36.0% of patients, but did not correlate significantly with the demographic and clinical characteristics of the patients, rate of first surgical recurrence, and time to second operation. CARD15 variants did not significantly affect the reoperation rate, irrespective of indications for surgery. Reoperation for CD is correlated with stenosis at initial surgery, but not with CARD15 gene variants. This finding does not justify more aggressive prophylactic therapy on the basis of CARD15 genotype.

Twenty-Year Surgical Experience With Congenital Supravalvar Aortic Stenosis

Congenital supravalvar aortic stenosis (SVAS) is an arteriopathy associated with Williams-Beuren syndrome and other elastin gene deletions. Our objectives were to review outcomes of congenital SVAS repair and to compare prosthetic patch repair techniques to all-autologous slide aortoplasty. Congenital SVAS repairs from 1988 to 2008 were retrospectively reviewed. Peak instantaneous gradients were estimated by Doppler interrogation. Variables were compared by either Student's t test or Fisher's exact test. Risk factors were analyzed by chi(2) test. Survival was estimated by the Kaplan-Meier method. Of 25 primary SVAS repairs, there were 10 all-autologous slide aortoplasties and 15 prosthetic patch aortoplasties. The prosthetic patch group included the Doty technique (n = 9), patch-augmented slide aortoplasty (n = 3), modified Brom technique (n = 1), interposition graft (n = 1), and two-sinus patch with transverse arch augmentation (n = 1). There was 1 early and 1 late death. Cumulative survival for all patients was 96% at 5 and 10 years. Event-free survival did not differ between groups (p = 0.481). There were 2 late reoperations (both were prosthetic patch patients with bicuspid aortic valve: 1 with recurrent aortic valve stenosis and 1 with aortic insufficiency). Bicuspid aortic valve was the only risk factor for reoperation (p = 0.003). Three patients weighing less than 10 kg with diffuse disease underwent attempted slide aortoplasty: 2 required patch augmentation and 1 had a recurrent gradient in less than 1 year postoperatively. Outcomes after SVAS repair were good by any technique. No advantage to all-autologous slide aortoplasty was apparent at current follow-up. Based on our experience, slide aortoplasty is not recommended for small patients with diffuse disease.

Mitral valve repair for degenerative disease with leaflet prolapse: to improve long-term outcomes

Residual mitral regurgitation (MR) is a risk factor of reoperation. Here we report the midterm results of mitral valve repair for degenerative disease with mitral valve prolapse and identify important factors for durable repair. From April 1999 to September 2007, 116 patients with leaflet prolapse (59 men; mean age 63 years) underwent mitral valve repair; they consisted of 19 anterior, 67 posterior, 23 bileaflet, and 7 isolated commissures. The mean clinical and echocardiographic follow-ups were at 4.1 +/- 2.3 and 3.3 +/- 2.4 years, respectively. Altogether, 12 patients showed recurrent moderate or severe MR during the follow-up period; and 10 of the 12 patients (83.8%) had recurrent moderate or severe MR within 1.5 years. Causes of early MR recurrence were dehiscence of sutured segments and ineffectiveness of the artificial chords. The rates of freedom from reoperation at 3 and 7 years were 95.3% +/- 2.0% and 91.0% +/- 4.7%, respectively. The rates of freedom from recurrent moderate or severe MR at 3 and 7 years were 90.5% +/- 2.9% and 83.8% +/- 5.9%, respectively. The prevention of dehiscence of the sutured segment and reestablishment of coaptation using artificial chords are imperative to maintain the durability of mitral valve repair for patients with degenerative disease.