Isolated Atrial Lead Conduction Delay following Right Atrial Radiofrequency Maze Procedure

A 60-year-old man with a dual-chamber implantable cardioverter defibrillator and severe dyspnea on exertion due to apical hypertrophic cardiomyopathy underwent a septal myectomy and radiofrequency maze procedure. Following the procedure a persistent delay in atrial sensing was observed and was most likely a result of iatrogenic conduction delay from right atrial ablation lines. These observations suggest that atrial conduction properties can be altered during the surgical maze procedure and should be considered in the differential diagnosis of sensing or pacing malfunction

When should a mechanical tricuspid valve replacement be considered?

BackgroundIsolated mechanical tricuspid valve replacement (mTVR) is uncommon, early mortality is reported to be high, and little is known regarding the long-term outcome. We sought to evaluate the long-term outcome of mTVR.MethodsFrom 1980 to 2007, isolated mTVR was performed in 64 patients (33 men) at our institution; the median age was 45.5 years (6-71 years). There were 2192 tricuspid valve (TV) repairs and 137 isolated bioprosthetic TV replacements during the same time interval. Valve dysfunction was caused by congenital TV abnormality in 45 patients (70%), carcinoid heart disease in 13 (20%), traumatic TV regurgitation in 3 (5%), and other reason in 3 (5%). Twenty-three patients (36%) had at least 1 previous cardiac procedure (TV repair in 8 and bioprosthetic TV replacement in 7).ResultsMechanical prostheses used included Starr-Edwards (before 1993) in 36 patients (56%) and bileaflet prostheses in 28 (44%). Concomitant procedures included atrial septal defect closure in 28 (44%), arrhythmia surgery in 11 (17%), and pulmonary valvectomy for carcinoid disease in 10 patients (16%). Early mortality occurred in 5 patients (7.8%). Early morbidity included a permanent pacemaker in 9 (14%) and reexploration for bleeding in 2 patients (3%). Mean follow-up was 6 years (maximum 22.4 years). Five- and 10-year survival was 65% and 58%, respectively. There was no valve-related mortality. Late morbidity included valve thrombosis in 5 patients (8%); 3 were managed nonoperatively and 2 underwent TV rereplacement.ConclusionsIsolated mTVR still leads to increased early mortality. A mechanical valve can be considered in select situations when anticoagulation is necessary and in the presence of good right ventricular function

Does the dilated ascending aorta in an adult with congenital heart disease require intervention?

ObjectivesThere is increasing attention to prophylactic replacement of the moderately dilated ascending aorta at aortic valve surgery. Moderate ascending aortic dilatation is common in adult patients with conotruncal anomalies. There are no data outlining actual risk of progressive ascending aortic dilatation or dissection to provide management guidelines.MethodsFrom December 1973 through January 2008, 81 consecutive adults (median age, 34 years; range, 18--59 years) with conotruncal anomalies underwent operation on the aortic root, ascending aorta, or aortic valve. Primary cardiac diagnoses included tetralogy of Fallot with or without pulmonary atresia in 60 patients, truncus arteriosus in 12, double-outlet right ventricle in 6, and other in 3. Indications for operation included aortic regurgitation in 69 patients, supracoronary ascending aneurysm in 16, aortic stenosis in 5, and other in 8. Median ascending aortic size was 45 mm (23--80 mm).ResultsOperations included isolated aortic valve repair/replacement in 63 patients, combined aortic valve replacement and reduction aortoplasty in 9, aortic root replacement in 7, and isolated ascending aortic replacement in 2. Four patients required reoperation during a median follow-up of 3.8 years (maximum 31 years). There were no ascending aortic reoperations after previous reduction aortoplasties or supracoronary ascending aortic grafts, and there were no late aortic dissections.ConclusionsModerate ascending aortic enlargement is common among patients with conotruncal anomalies coming to operation, but aortic dissection is rare, as is subsequent need for aortic reoperation. Despite current enthusiasm for prophylactic operations on the ascending aorta in patients with acquired disease, these data suggest that the moderately dilated aorta in this setting may be observed

Outcome of Mildly Symptomatic or Asymptomatic Obstructive Hypertrophic Cardiomyopathy A Long-Term Follow-Up Study

ObjectivesThe purpose of this study was to characterize the prognosis of minimally symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM).BackgroundRecent data have suggested that obstruction may be present in the majority of HCM patients, irrespective of cardiac symptoms. The prognosis of minimally symptomatic obstructive HCM remains poorly defined.MethodsWe examined 544 consecutive adult patients (age 59 ± 16 years; 55% men) with obstructive HCM documented by Doppler echocardiography who were free of severe cardiac symptoms, and we performed clinical follow-up (median 9.3 years).ResultsThere was only a slight excess mortality of the cohort in comparison to the expected survival of a similar U.S. general population (10-year observed vs. expected survival, 69.3% vs. 71.9%; p = 0.04) and 46% of the deaths were attributable to noncardiac causes. However, there was a clear relation between increasing severity of the left ventricular outflow tract (LVOT) gradient and outcome. For patients with high resting gradients (Doppler peak velocity >4 m/s), survival was significantly impaired (53% at 10 years; p = 0.001 vs. expected), and death or severe symptoms occurred in 68% of these patients within 10 years after the initial evaluation. Conversely, there was no impairment of long-term survival for patients with less-severe resting obstruction. Independent predictors of mortality in the entire cohort were age, prior stroke, and LVOT gradient severity.ConclusionsPatients with obstructive HCM and mild or no symptoms have only slight excess mortality. However, patients with markedly elevated resting LVOT gradients are at a high risk of heart failure and death. These findings may have important implications for therapy, including the timing of septal reduction therapy

Increased risk of acute kidney injury in patients undergoing tricuspid valve surgery

OBJECTIVES We aimed to determine which patients undergoing tricuspid valve (TV) surgery are at increased risk for acute kidney injury (AKI). METHODS We reviewed 951 patients [mean age 67 ± 13 years, 573 (60%) female] having TV surgery between 2000 and 2007. Analysis focused on clinical outcome; AKI was defined by the consensus RIFLE criteria (risk, injury, failure). RESULTS Surgical procedures included isolated TV surgery in 224 (24%) and TV surgery in conjunction with another cardiac operation in 727 (76%) patients. TV surgery involved redo surgery in 395 (42%). The incidence of postoperative AKI was 30% (n = 285), and 75 (7.9%) of these patients required renal replacement therapy. AKI stratified by increased RIFLE class was associated with worse postoperative outcomes (prolonged intubation, length of hospital stay and mortality; P < 0.001 for each variable). For patients with AKI, odds ratio for mortality was 4.2 [95% confidence interval (CI) 3.2-5.4, P < 0.001; area under receiver operating curves 0.85 (95% CI 0.80-0.91)], and 2.3 (95% CI 1.9-2.9, P < 0.001) for prolonged intubation for each increase in RIFLE class. Independent risk factors for AKI were older age, male gender, previous surgery, preoperative anaemia, length of cardiopulmonary bypass and TV replacement. Importantly, preoperative creatinine and pulmonary artery pressure were not independently associated with AKI. CONCLUSIONS TV surgery carries a high incidence of postoperative AKI that is associated with adverse outcome. The use of the RIFLE criteria allows comparison with prior studies and is an important predictor of early mortality. The estimation of patient risk for AKI should be based on multivariable predictio

Functional Status After Operation for Ebstein Anomaly The Mayo Clinic Experience

ObjectivesThe objective of this study was to review the long-term functional outcome of patients with Ebstein anomaly who had cardiac operation at our institution.BackgroundEbstein anomaly is a spectrum of tricuspid valvular and right ventricular dysplasia. Many patients will require operation in an attempt to improve quality of life.MethodsFrom April 1, 1972, to January 1, 2006, 539 patients with Ebstein anomaly underwent 604 cardiac operations at the Mayo Clinic in Rochester, Minnesota. Patient records were reviewed, and all patients known to still be alive were mailed a medical questionnaire or contacted by telephone.ResultsAt the initial operation at our institution, the mean age of the patients was 24 years (range 8 days to 79 years) and 53% were female patients. Survival at 5, 10, 15, and 20 years was 94%, 90%, 86%, and 76%, respectively. Survival free of late reoperation was 86%, 74%, 62%, and 46% at 5, 10, 15, and 20 years, respectively. Surveys were returned by 285 of 448 (64%) patients known to be alive at the time of this study. Two hundred thirty-seven (83%) patients were in New York Heart Association functional class I or II, and 34% were taking no cardiac medication. One hundred three patients (36%) reported an incident of atrial fibrillation or flutter, 5 patients (2%) reported having had endocarditis, and 1 patient (<1%) reported having a stroke. There were 275 pregnancies among 82 women. The recurrence of congenital heart disease was reported in 9 of 232 (3.9%) liveborn children.ConclusionsPatients have good long-term survival and functional outcomes after undergoing surgery for Ebstein anomaly. Atrial arrhythmias are common both before and after surgery. Many patients have had one or more successful pregnancies with a low-recurrence risk of congenital heart disease