The angle of the components of the common atrioventricular valve predicts the outcome of surgical correction in patients with atrioventricular septal defect and common atrioventricular junction

Background: Three-dimensional echocardiography offers new insights into valvar function in atrioventricular septal defects (AVSDs). The aim of this study was to identify a morphological marker to predict the functional outcomes of left atrioventricular valves (AVVs) following the repair of AVSDs.Methods: Twenty-nine consecutive patients were evaluated preoperatively using 2-dimensional and 3-dimensional echocardiography. The angle of the AVV relative to the crux of the heart was measured in multiplanar review mode.Results: The severity of postoperative left AVV regurgitation was correlated with preoperative valvar angle, being more acute in patients with moderate or severe regurgitation (mean, 57 ± 13° vs 83 ± 9° in patients with no or mild regurgitation; P = .002). Angles ? 59° predicted severe regurgitation with 79% specificity.Conclusions: Multiplanar review of 3-dimensional data sets is valuable for the assessment of the functional morphology of AVSD valves. Using this technique, more acute AVV angles predicted increased likelihood of severe regurgitation following surgical repair.<br/

Leukodepletion reduces renal injury in coronary revascularization: a prospective randomized study

Background: cardiopulmonary bypass (CPB) is an important contributor to renal failure, which is a well-recognized complication after coronary artery bypass grafting (CABG). Leukodepletion reduces CPB-associated inflammation and resultant end-organ injuries. However, its effectiveness in renal protection has not been evaluated in a prospective randomized clinical setting.Methods: forty low-risk patients awaiting elective CABG with normal preoperative cardiac and renal function were prospectively randomized into those undergoing nonpulsatile CPB without (group A: N = 20) and with leukodepletion (group B: N = 20). Renal glomerular and tubular injury were assessed by urinary excretion of microalbumin and retinol binding protein (RBP) indexed to creatinine (Cr), respectively. Daily measurements were taken from admission to postoperative day 5. Fluid balance, serum creatinine, and blood urea were also monitored.Results: no mortality or renal complication occurred. Both groups had similar demographic makeups, Parsonnet scores, extents of coronary revascularization and, durations of CPB and aortic cross-clamping. Daily fluid balance, serum creatinine, and blood urea remained comparable in both groups throughout the study period. From equal preoperative values, a significantly higher release of urinary RBP:Cr (7,807 ± 2,227 vs 3,942 ± 2,528; p &lt; 0.001) and urinary microalbumin:Cr (59.4 ± 38.0 vs 4.7 ± 6.7; p &lt; 0.0001) occurred in group A, peaking on day 1 before returning to approximate baseline levels.Conclusions: although clinically overt renal complications were absent, sensitive indicators revealed significantly more injury to both renal tubules and glomeruli after nonpulsatile CPB without leukodepletion. These data suggest that leukocytes play an important role in post-CPB renal dysfunction, and leukodepletion may offer some renal protection in low-risk patients during CABG

Autotransfusion decreases blood usage following cardiac surgery - a prospective randomized trial

Introduction: 10% of blood issued by the National Blood Service (220 000) is utilised in cardiac procedures. Transfusion reactions, infection risk and cost should stimulate us to decrease this transfusion rate. We tested the efficacy of autotransfusion of washed postoperative mediastinal fluid in a prospective randomized trial.Patients and methods: 166 patients undergoing coronary artery bypass grafting (CABG), valve or CABG+valve procedures were randomized into three groups. The indication for transfusion was a postoperative haemoglobin (Hb) &lt;10g/l or a packed cell volume (PCV) &lt;30. When applicable, group A patients received washed post-operative drainage fluid. Group B all received blood processed from the cardiopulmonary bypass (CPB) circuit following separation from CPB and if appropriate washed post-operative drainage fluid. Group C were controls. Groups were compared using analysis of variance.Results: There was no significant difference in age, sex, type of operation, CPB time and preoperative Hb and PCV between the groups. Blood requirements were as shown. [see table 3 in main text]Twelve patients in group A and 10 in group B did not require a homologous transfusion following processing of the mediastinal drainage fluid.Conclusion: Autotransfusion of washed postoperative mediastinal fluid can decrease the amount of homologous blood transfused following cardiac surgery. There was no demonstrable benefit in processing blood from the CPB circuit as well as mediastinal drainage fluid

Risk of reoperation for structural failure of aortic and mitral tissue valves

In order to assess the risk of reoperation in the case of a failing stented tissue valve, 259 patients (118 males, 141 females; mean age 60.1 ± 15.4 years) underwent redo valve replacement. Of these patients, 94 (36.3%) underwent redo aortic valve replacement (AVR), 105 (40.5%) redo mitral valve replacement (MVR), and 60 (23.2%) redo aortic and mitral valve replacement (DVR). Twenty patients (7.7%) had previous coronary artery bypass grafting (CABG); further CABG were performed in 32 cases (12.4%). Preoperatively, 216 patients (83.3%) were in NYHA functional class III or IV. Early mortality was (6.5%; n = 17). A higher preoperative NHYA status (p &lt;0.0004) and emergency surgery (p &lt;0.0001) were associated with an increased risk of operative death. Age at operation (p = 0.45), previous CABG (p = 0.45), position of the valve replaced (p = 0.2), type of implant (p = 0.06) and presence of coronary artery disease (p = 0.51) were not associated with a significant risk of operative mortality. A failing tissue valve may be replaced, with acceptable operative mortality and morbidity. The trend towards reducing the age at which tissue valve implantation is performed may be justified

Hepatic changes in the failing Fontan circulation

Background: The failing Fontan circulation is associated with hepatic impairment. The nature of this liver injury is poorly defined.Objective: To establish the gross and histological liver changes of patients with Fontan circulation relative to clinical, biochemical and haemodynamic findings.Methods: Patients were retrospectively assessed for extracardiac Fontan conversion between September 2003 and June 2005, according to an established clinical protocol. Twelve patients, mean age 24.6 (range 15.8–43.4) years were identified. The mean duration since the initial Fontan procedure was 14.1 (range 6.9–26.4) years.Results: Zonal enhancement of the liver (4/12) on CT was more common in patients with lower hepatic vein pressures (p = 0.007), and in those with absent cardiac cirrhosis on histological examination (p = 0.033). Gastro-oesophageal varices (4/12) were more common in patients with higher hepatic vein pressure (21 (6.3) vs 12.2 (2.2) mm Hg, p = 0.013) and associated with more advanced cirrhosis (p = 0.037). The extent of cirrhosis (7/12) was positively correlated with the hepatic vein pressure (r = 0.83, p = 0.003). A significant positive correlation was found between the Fontan duration and the degree of hepatic fibrosis (r = 0.75, p = 0.013), as well as presence of broad scars (r = 0.71, p = 0.021). Protein-losing enteropathy (5/12) occurred more frequently in patients with longer Fontan duration (11.7 (3.2) vs 17.9 (6.1) years, p = 0.038).Conclusions: Liver injury, which can be extensive in this patient group, is related to Fontan duration and hepatic vein pressures. CT scan assists non-invasive assessment. Cardiac cirrhosis with the risk of developing gastro-oesophageal varices and regenerative liver nodules, a precursor to hepatocellular carcinoma, is common in this patient group