To the Editor: We read with interest the description by El-Hamamsy and colleagues1El-Hamamsy I. Willerson J.T. Yacoub M.H. Preserved homograft function 32 years after surgery in a young patient.J Thorac Cardiovasc Surg. 2010; 139 (Epub 2010 Mar 24): e141-e142Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar of a young woman who received a homovital homograft aortic root replacement that remains in situ with preserved function 32 years later. The description of this patient echoes our experience with noncryopreserved aortic homografts. In the mid to late 1970s at Southampton General Hospital, we too favored homografts for aortic valve replacement, especially in young women. Our preference was antibiotic-sterilized homograft valves that remained in storage refrigerated at 4°C. The majority of homografts were implanted within 8 weeks, but storage extended to as long as 17 weeks. For isolated valvular pathology, implantation was ordinarily subcoronary using the techniques described by Ross2Ross D.N. Homograft replacement of the aortic valve.Lancet. 1962; 2: 487Abstract PubMed Scopus (495) Google Scholar and Barratt-Boyes.3Barratt-Boyes B.G. A method for preparing and inserting a homograft aortic valve.Br J Surg. 1965; 52: 847-856Crossref PubMed Scopus (69) Google Scholar Subcoronary implantation, although technically challenging, lends itself to a significantly less hazardous reoperation than root or mini-root replacement. In our experience, the durability of subcoronary antibiotic-sterilized refrigerated homografts has exceeded that of tissue prostheses or cryopreserved allografts, particularly in children and young adults. Among our cohort of 200 consecutive young adults receiving subcoronary homografts, 7 were alive with their original homograft in situ between 25 and 29.8 years later at the time of our last report in 2007.4Hickey E. Langley S.M. Allemby-Smith O. Livesey S.A. Monro J.L. Subcoronary allograft aortic valve replacement: parametric risk-hazard outcome analysis to a minimum of 20 years.Ann Thorac Surg. 2007; 84: 1564-1570Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Since the time of our last report, 1 of these 7 patients underwent reoperation 32.3 years after the original valve implantation. The other 6 patients remain alive and free from reoperation (maximum of 30 years with the latest echocardiogram reporting mild regurgitation, peak instantaneous gradient of 27 mm Hg, and normal ventricular function and dimensions). Overall freedom from reoperation in survivors was approximately 40% at 20 years. Together with our experience, the case reported by the London group1El-Hamamsy I. Willerson J.T. Yacoub M.H. Preserved homograft function 32 years after surgery in a young patient.J Thorac Cardiovasc Surg. 2010; 139 (Epub 2010 Mar 24): e141-e142Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar adds credence to the suggestion that noncryopreserved allograft prostheses may outperform present-day cryopreserved allografts (and indeed perhaps modern tissue bioprostheses). Limited availability of allografts provided the impetus for the widespread introduction of cryopreservation with its potential for longer (perhaps indefinite) storage. Nevertheless, limited availability relates primarily to logistics of procurement and consent, which may be mutable hurdles. Perhaps it is time to reexamine the biologic properties of noncryopreserved allograft implants with a view to addressing the logistics of donor acquisition and valve procurement if necessary. Preserved homograft function 32 years after surgery in a young patientThe Journal of Thoracic and Cardiovascular SurgeryVol. 139Issue 6PreviewThe quest for the ideal valve substitute, namely, a valve requiring no anticoagulation and free from early valve degeneration with a good hemodynamic profile, remains unsolved despite continued research over the past 50 years. The present report describes a well-functioning aortic root homograft 32 years after implantation. It illustrates the potential longevity of implanted tissue valves and highlights the need to better understand the cellular and molecular physiology of heart valves as well as the mechanisms responsible for structural valve degeneration. Full-Text PDF

Background: We sought to determine the long-term performance of homograft and truncal valve after complete repair of common arterial trunk.Methods: From January 1964 to June 2008, 32 patients (median age, 14 days; range, 5 days to 2.5 years) underwent primary homograft repair of common arterial trunk. Twenty-four (75%) were neonates. The homograft used in the right ventricular outflow tract was aortic in 24 patients and pulmonary in 8 patients (mean diameter, 15.8 +/- 3.5 mm; median diameter, 16 mm [range, 8-24 mm]). The median follow-up was 24.5 years (range, 5.6 months to 43.5 years).Results: There were 3 hospital deaths and 1 late death. The actuarial survival at 30 years was 83.1% +/- 6.6%. Of the 28 survivors, 25 reoperations were performed in 19 (76%) patients. The mean and median times to homograft reoperation were 11.5 +/- 7.4 and 12.1 years (range, 1.0-26.1 years), respectively. Overall freedom from homograft reoperation after 10, 20, and 30 years was 68.4% +/- 8.7%, 37.4% +/- 9.5%, and 26.7% +/- 9.3%, respectively. Twelve patients retained the original homografts at a median follow-up of 16.4 years (range, 0-30.2 years). Six underwent a truncal valve replacement with a mechanical prosthesis at a median of 10.5 years (range, 3.4-22 years) after truncus repair. Freedom from truncal valve replacement at 10 and 30 years was 93.1% +/- 4.7% and 81.8% +/- 8.9%, respectively. In the 22 surviving patients who did not undergo truncal valve replacement, the peak truncal valve gradient was 8.9 +/- 8.3 mm Hg at a median follow-up of 24.5 years (range, 5.6 months to 32.9 years). At the last follow-up, 27 (96.4%) patients had good left ventricular function, and 24 patients (85.7%) were New York Heart Association class I.Conclusions: Oversizing the homograft at the time of the initial repair can lead to a homograft lasting more than 12 years. During long-term follow-up, 20% of patients require truncal valve replacement. (J Thorac Cardiovasc Surg 2010;140:325-9)

The paper by Fratz et al . describes the follow-up of 188 children who had balloon aortic valvuloplasty (AoVP) between 1986 and 2004. Moderate or severe aortic regurgitation occurred more often in the 68 neonates—in whom there was significant early mortality—than in the 120 older children; however, AoVP produced a satisfactory reduction in aortic valve gradient in both groups. Reintervention-free status declined in both groups over time and, at 10 years follow-up, 59% of the neonates and 70% of the older group were intervention free. These results show that AoVP postpones the need for aortic valve surgery and has the advantage of being less invasive than initial surgical valvotomy. AoVP is, however, associated with an increased risk of aortic regurgitation and, in neonates, early subsequent aortic valve surgery is likely to be needed.

BACKGROUND:Conducting system defects are common in patients with aortic valve disease. Aortic valve replacement may result in further conduction abnormalities and necessitate permanent pacemaker implantation (PPM). We sought to identify the contemporary incidence and predictors for early postoperative PPM in patients undergoing isolated aortic valve replacement.METHODS:Data were analyzed from 354 consecutive patients undergoing isolated aortic valve replacement at a referral cardiac unit during a 30-month period; data were unavailable on 4 patients and a further 8 had undergone preoperative PPM. Results for the remaining 342 patients (97%; mean age, 67 +/- 14 years), of whom 212 were males, are presented. The major indications for aortic valve replacement were valvular stenosis (n = 224), regurgitation (n = 70), or infective endocarditis (n = 25). Preoperative conducting system disease was present in 26% of patients.RESULTS:In-hospital mortality was 1.8% (6 of 342 patients). Postoperatively 29 patients (8.5%) required early PPM, of which 26 were during the index admission. Patients with preoperative conducting system disease (16% versus 6%; p = 0.004) and valvular regurgitation (16% versus 7%; p = 0.01) were more likely to require PPM as opposed to those without. Preoperative conducting system disease was the only independent predictor of PPM (p < 0.01); the relative risk of PPM requirement in this group was 2.88 (95% confidence interval, 1.31 to 6.33).CONCLUSIONS:Permanent pacemaker implantation requirement after aortic valve replacement is a common occurrence, and should be discussed as part of the preoperative consent process. Preexisting conducting disease and preoperative aortic regurgitation were predictors of PPM requirement.

BACKGROUND:Differences in sterilization, preservation, and implantation have been implicated in aortic allograft longevity. We report follow-up to 30 years of patients from a single unit who underwent aortic valve replacement with aortic allografts sterilized in antibiotics and refrigerated at 4 degrees C.METHODS:Two hundred consecutive patients underwent subcoronary allograft aortic valve replacement and have been followed up to a minimum of 20 and maximum of 30 years. Follow-up was 96% complete. Parametric hazard phase modeling was used to identify incremental predictors of time-related risk.RESULTS:Early mortality was 1.5%. Kaplan-Meier actuarial survival, including early death, was 81.2% +/- 2.8% (mean +/- standard error of the mean), 58.0% +/- 3.7%, and 52% +/- 5.1% at 10, 20, and 25 years, respectively. Freedom from reoperation for any reason was 86.4% +/- 2.6%, 39.6% +/- 5.2%, and 35.0% +/- 5.4% at 10, 20, and 25 years, respectively. Larger implanted valve, reexploration for bleeding, previous cardiac surgery, and operative rank were independent risks for reoperation. Early mortality in reoperations was 5.1%. Allograft endocarditis has occurred in 6 patients, giving an overall freedom of 94% at 25 years. Seven patients of the original cohort are known to be alive with their original allograft valve in situ, and of these the longest follow-up period is 29.8 years.CONCLUSIONS:The use of antibiotic-sterilized allografts for subcoronary aortic valve replacement confers low operative mortality and excellent long-term survival with durability matching any other nonmechanical device. Significantly reduced time-related risk of reoperation and excellent internal to external diameter ratio renders allograft aortic valve replacement especially ideal for smaller roots.

Objective: To assess the impact of early corrective surgery on the short and medium term outcome in tetralogy of Fallot (TOF). Materials and methods: All patients under 12 months of age undergoing correction of isolated TOF between February 1997 and July 2003 were reviewed retrospectively. Outcome data for mortality, post-operative care management, major morbidity and clinical follow-up were analysed. Results: Fifty-two operations were performed. The mean age at surgery was 5 months (range 1-12) of whom 16 (30.8%) were less than 3 months old, including 2 neonates, 22 (42.3%) were 3-6 months old and 14 (26.9%) were 7-12 months old. There was 1 (1.9%) early death caused by a cerebrovascular accident and 1 (1.9%) late death secondary to acute infective endocarditis. There were no differences in post-operative morbidities attributable to age. Patients under 3 months old required greater duration of post-operative ventilation, ITU stay and in-hospital stay. At a mean follow-up of 4.0 years (range 1.5-8.0), 33 (63.5%) patients had well-tolerated pulmonary regurgitation (PR) and 3 (5.8%) patients required reoperation for right ventricular outflow tract obstruction (RVOTO). All patients had right bundle-branch-block but with QRS < 150 ms. Conclusion: Early definitive repair of TOF can be performed safety on patients under 6 months old. Age at surgery does not appear to affect the medium term haemodynamic outcome. However, early surgery does escalate the need for ICU care. This data suggests repair in asymptomatic patients be delayed until 3-6 months of age. (c) 2006 Elsevier B.V. All rights reserved.

The results of open heart surgery in infants have steadily improved. The performance of corrective surgery very early in life has thereby been encouraged. We report four patients who underwent successful surgical correction within 24 h of birth. Two patients with total anomalous pulmonary venous drainage and one patient with pulmonary atresia and intact septum were corrected with the aid of profound hypothermia by the combined surface and bypass cooling technique. Cardiopulmonary bypass alone was used for the fourth patient with aortic stenosis. The usual surgical techniques can be applied successfully to infants even within 24 h of life.

The number of patients with adult congenital heart disease is expected to increase by 25% during this decade, so that by 2010 there will be more patients undergoing surgery for congenital heart disease over 16 years of age than under

Objective: The multi-national and multi-institutional collection of data on outcomes in Congenital Heart Surgery (CHS) provides the possibility of analysis of results of treatment and may result in further improvement of the quality of care. The verification of data as far as the completeness and accuracy is necessary to give confidence to all, sides-the patients, centers and regulatory authorities. The source data verification (SDV) although difficult, appears possible even in such a large-scale database.Methods: Out of 5.274 patients and 5.612 procedures data of 2003, collected in the database, 1.703 (32.3%) and 1.895 (33.8%), respectively, have been verified at five sites on following fields: IPPV time, date of birth, date of admission, date of surgery, date of discharge/mortality, body weight, case category, CPB time, AoX time, Circulatory arrest time. SDV was performed at five sites by two database officers using the sources of information different to the local copy of the database (patients' files, operation notes, perfusion charts, OR Books). Verification was performed between June 1st and July 31st 2004. Statistical analysis was performed using R-project software, ver. 2.0.0. and Welch's t-test for comparison of continuous variables. P-vatue > 0.05 was used as statistically significant difference between groups.Results: Pre- and post-verification mortalities in all groups showed no significant differences although seven deaths out of 68 (10.27%) were missed. None of the other verified fields showed significant differences after verification.Conclusions: Source Data Verification showed no statistically significant differences between verified and non-verified data on 30 days mortality, LOS, age, body weight, CPB time, AoX and Circulatory arrest time. IPPV time was not available in 58.6% procedures. (c) 2005 Elsevier B.V. All rights reserved.

Acute myocarditis is characterized by the development of rapid life-threatening congestive heart failure and arrhythmias. In many cases with hemodynamic compromise, medical therapy and mechanical support alone are not sufficient. Various surgical procedures have been tried to bridge patients with myocarditis to both transplant and recovery. Mitral regurgitation is a frequent association with end stage cardiomyopathy and predicts poor outcome. Mitral annuloplasty is well-established in adults with ischemic and dilated cardiomyopathy and the results are superior to medical therapy alone and are comparable to cardiac transplantation. However, its effectiveness and use is not well-established in children with cardiomyopathy. We report our experience in two children.

When the preoperative assessment suggests that the pulmonary valve annulus is of adequate size, repair through the right atrium seems the best option. However, when the annulus is obviously small and a transannular patch will be needed, a ventriculotomy will be needed, and a small extension allows an adequate view of the VSD. This is a very satisfactory approach, and particularly when the repair is performed in infancy (which seems to be the current trend), late arrhythmias are very infrequent. When the annulus size is equivocal, either approach can be used and even a combination of ventricular and transatrial methods used to close the VSD.

patients with operated AADA and deep hypothermic circulatory arrest (DHCA) up to 30 minutes is similar with an age and sex matched standard population. 10 Plasma concentrations of D-dimer are an interesting tool and a valuable addition in the diagnostic work-up of AADA.However, prediction of mortality and indication to proceed or not with emergency surgery should certainly not be based on a D-dimer, or on any other laboratory value.The majority of patients are suitable for surgery and should therefore be sent immediately to a cardiac surgical department, where surgery can be performed with a low mortality and results in the majority of patients having a good mid-term outcome with normal quality of life.