Fourteen years' experience with 501 subcoronary Ross procedures: Surgical details and results

ObjectiveDuring the past decade the Ross procedure using the full root has become the predominant surgical technique. However, progressive autograft dilatation and eventual failure remain a concern. Here we report on the surgical techniques and results of the subcoronary technique over a 14-year period.MethodsA total of 501 patients (mean age, 44.9 ± 12.9 years; 117 female; 384 male) were operated on from June 1994 to December 2007. The follow-up database, with a completeness of 98.2%, was closed on December 2008, comprising of 2931 patient-years with a mean follow-up of 5.9 ± 3.6 years (range, 0.1–14.1 years).ResultsSurgical details are presented. Early and late mortality were 0.4% (n = 2) and 4% (n = 20), respectively, valve-related mortality was 1.2% (n = 6), whereas the overall survival did not differ from that of the normal population. Neurologic events occurred in 22 patients, major bleeding in 9, autograft endocarditis in 8, and homograft endocarditis in 10. Freedom from autograft and homograft reoperation was 91.9% at 10 years. For the majority of patients, hemodynamics was excellent and no root dilatation was observed.ConclusionsMidterm results after the original subcoronary Ross procedure are excellent, including normal survival and low risk of valve-related morbidity. Longer-term results are necessary for continuous judgment of the subcoronary technique

A large genome-wide association study of age-related macular degeneration highlights contributions of rare and common variants.

This is the author accepted manuscript. The final version is available from Nature Publishing Group via http://dx.doi.org/10.1038/ng.3448Advanced age-related macular degeneration (AMD) is the leading cause of blindness in the elderly, with limited therapeutic options. Here we report on a study of >12 million variants, including 163,714 directly genotyped, mostly rare, protein-altering variants. Analyzing 16,144 patients and 17,832 controls, we identify 52 independently associated common and rare variants (P < 5 × 10(-8)) distributed across 34 loci. Although wet and dry AMD subtypes exhibit predominantly shared genetics, we identify the first genetic association signal specific to wet AMD, near MMP9 (difference P value = 4.1 × 10(-10)). Very rare coding variants (frequency <0.1%) in CFH, CFI and TIMP3 suggest causal roles for these genes, as does a splice variant in SLC16A8. Our results support the hypothesis that rare coding variants can pinpoint causal genes within known genetic loci and illustrate that applying the approach systematically to detect new loci requires extremely large sample sizes.We thank all participants of all the studies included for enabling this research by their participation in these studies. Computer resources for this project have been provided by the high-performance computing centers of the University of Michigan and the University of Regensburg. Group-specific acknowledgments can be found in the Supplementary Note. The Center for Inherited Diseases Research (CIDR) Program contract number is HHSN268201200008I. This and the main consortium work were predominantly funded by 1X01HG006934-01 to G.R.A. and R01 EY022310 to J.L.H

Impact of cardiac magnet resonance imaging on management of ventricular septal rupture after acute myocardial infarction

A 74-year-old man was admitted to the cardiac catheterization laboratory with acute myocardial infarction. After successful angioplasty and stent implantation into the right coronary artery, he developed cardiogenic shock the following day. Echocardiography showed ventricular septal rupture. Cardiac magnet resonance imaging (MRI) was performed on the critically ill patient and provided detailed information on size and localization of the ruptured septum by the use of fast MRI sequences. Moreover, the MRI revealed that the ventricular septal rupture was within the myocardial infarction area, which was substantially larger than the rupture. As the patient’s condition worsened, he was intubated and had intra-aortic balloon pump implanted, and extracorporeal membrane oxygenation was initiated. During the following days, the patient’s situation improved, and surgical correction of the ventricular septal defect could successfully be performed. To the best of our knowledge, this case report is the first description of postinfarction ventricular septal rupture by the use of cardiac MRI in an intensive care patient with cardiogenic shock and subsequent successful surgical repair

Gentamicin-collagen sponge reduces sternal wound complications after heart surgery:A controlled, prospectively randomized, double-blind study

ObjectiveProphylactic retrosternal placement of a gentamicin-collagen sponge has been the subject of several recent clinical studies and is a matter of controversy. The present study is the first controlled, prospective, randomized, double-blind, single-center study to investigate the efficacy of a retrosternal gentamicin-collagen sponge in reducing sternal wound complications after heart surgery.MethodsFrom June 2009 to June 2010, 720 consecutive patients who underwent median sternotomy were assigned to a control placebo group (collagen sponge) or an intervention group (gentamicin-collagen sponge). All patients received guideline-compliant perioperative antibiotic prophylaxis. The primary end point was the occurrence of deep sternal wound infections within 30 days of index surgery (follow-up period). Secondary end points were the occurrence of superficial sternal wound infections requiring treatment, as well as further clinical parameters, including revision, bleeding volume, and need for transfusions during the follow-up period.ResultsA total of 720 of 994 patients (72.4%) were enrolled (control group: n = 367 vs intervention group: n = 353). Risk factors for sternal wound infection and demographic variables were comparable in the 2 groups. The incidence of deep sternal wound infections was 13 of 367 (3.52%) in the control group versus 2 of 353 (0.56%) in the intervention group (P = .014; adjusted odds ratio, 0.15; 95% confidence interval, 0.02–0.69). The numbers needed to treat relation for all sternal wound infections and deep sternal wound infections were 26 and 33, respectively. No statistically significant differences were demonstrated concerning secondary end points, such as postoperative bleeding and transfusion of red cell units, thrombocytes, and fresh-frozen plasma.ConclusionsRoutine prophylactic retrosternal use of a gentamicin-collagen sponge in patients undergoing cardiac surgery significantly reduces deep sternal wound infections

Rapid deployment valve system shortens operative times for aortic valve replacement through right anterior minithoracotomy

Background: There is growing evidence from the literature that right anterior minithoracotomy aortic valve replacement (RAT-AVR) improves clinical outcome. However, increased cross clamp time is the strongest argument for surgeons not performing RAT-AVR. Rapid deployment aortic valve systems have the potential to decrease cross-clamp time and ease this procedure. We assessed clinical outcome of rapid deployment and conventional valves through RAT. Methods: Sixty-eight patients (mean age 76 ± 6 years, 32% females) underwent RAT-AVR between 9/2013 and 7/2015. According to the valve type implanted the patients were divided into two groups. In 43 patients (R-group; mean age 74.1 ± 6.6 years) a rapid deployment valve system (Edwards Intuity, Edwards Lifesciences Corp; Irvine, Calif) and in 25 patients (C-group; mean age 74.2 ± 6.6 years) a conventional stented biological aortic valve was implanted. Results: Aortic cross-clamp (42.1 ± 12 min vs. 68.3 ± 20.3 min; p < 0.001) and bypass time (80.4 ± 39.3 min vs. 106.6 ± 23.2 min; p = 0.001) were shorter in the rapid deployment group (R-group). We observed no differences in clinical outcome. Postoperative gradients (R-group: max gradient, 14.3 ± 8 mmHg vs. 15.5 ± 5 mmHg (C-group), mean gradient, 9.2 ± 1.7 mmHg (R-group) vs. 9.1 ± 2.3 mmHg (C-group) revealed no differences. However, larger prostheses were implanted in C-group (25 mm; IQR 23–27 mm vs. 23 mm; IQR 21–25; p = 0.009). Conclusions: Our data suggest that the rapid deployment aortic valve system reduced cross clamp and bypass time in patients undergoing RAT-AVR with similar hemodynamics as with larger size stented prosthesis. However, larger studies and long-term follow-up are mandatory to confirm our findings

Preoperative serum h-FABP concentration is associated with postoperative incidence of acute kidney injury in patients undergoing cardiac surgery

Background Fatty acid binding protein (FABP) is an intracellular transport protein associated with myocardial damage size in patients undergoing cardiac surgery. Furthermore, elevated FABP serum concentrations are related to a number of common comorbidities, such as heart failure, chronic kidney disease, diabetes mellitus, and metabolic syndrome, which represent important risk factors for postoperative acute kidney injury (AKI). Data are lacking on the association between preoperative FABP serum level and postoperative incidence of AKI. Methods This prospective cohort study investigated the association between preoperative h-FABP serum concentrations and postoperative incidence of AKI, hospitalization time and length of ICU treatment. Blood samples were collected according to a predefined schedule. The AKI Network definition of AKI was used as primary endpoint. All associations were analysed using descriptive and univariate analyses. Results Between 05/2009 and 09/2009, 70 patients undergoing cardiac surgery were investigated. AKI was observed in 45 patients (64%). Preoperative median (IQR) h-FABP differed between the AKI group (2.9 [1.7–4.1] ng/ml) and patients without AKI (1.7 [1.1–3.3] ng/ml; p = 0.04), respectively. Patients with AKI were significantly older. No statistically significant differences were found for gender, type of surgery, operation duration, CPB-, or X-Clamp time, preoperative cardiac enzymes, HbA1c, or CRP between the two groups. Preoperative h-FABP was also correlated with the length of ICU stay (rs = 0.32, p = 0.007). Conclusions We found a correlation between preoperative serum h-FABP and the postoperative incidence of AKI. Our results suggest a potential role for h-FABP as a biomarker for AKI in cardiac surgery

FAK deficiency in cells contributing to the basal lamina results in cortical abnormalities resembling congenital muscular dystrophies

AbstractTargeted deletion of focal adhesion kinase (fak) in the developing dorsal forebrain resulted in local disruptions of the cortical basement membrane located between the neuroepithelium and pia-meninges. At disruption sites, clusters of neurons invaded the marginal zone. Retraction of radial glial endfeet, midline fusion of brain hemispheres, and gliosis also occurred, similar to type II cobblestone lissencephaly as seen in congenital muscular dystrophy. Interestingly, targeted deletion of fak in neurons alone did not result in cortical ectopias, indicating that fak deletion from glia is required for neuronal mislocalization. Unexpectedly, fak deletion specifically from meningeal fibroblasts elicited similar cortical ectopias in vivo and altered laminin organization in vitro. These observations provide compelling evidence that FAK plays a key signaling role in cortical basement membrane assembly and/or remodeling. In addition, FAK is required within neurons during development because neuron-specific fak deletion alters dendritic morphology in the absence of lamination defects

Age-related reoperation rate after the ross procedure: a report from the german ross registry

BACKGROUND AND AIM OF THE STUDY: An increasing number of young adult patients are choosing bioprostheses for aortic valve replacement (AVR). In this context, the Ross operation deserves renewed consideration as an alternative biological substitute. After both the Ross procedure and bioprosthetic AVR, reoperation rates remain a concern and may be related to age at surgery. Herein are reported details of freedom from reoperation after the Ross procedure for different age groups. METHODS: The reoperation rates of 1,925 patients (1,444 males, 481 females; mean age 41.2 ± 15.3 years) from the German Ross registry with a mean follow up of 7.4 ± 4.7 years (range: 0.00-18.51 years; total 12,866.6 patient-years) were allocated to three age groups: group I 60 years. RESULTS: At 10 years (respectively 15 years) of follow up, freedom from reoperation was 86% (76%) in group I, 93% (85%) in group II, and 89% (83%) in group III. CONCLUSION: There is some evidence that, at least during the first 10 and 15 years after AVR, the Ross procedure provides a significantly lower reoperation rate in young adult and middle-aged patients aged < 60 years. This information may be of interest to the patients' or physicians' decision-making for aortic valve surgery