12 research outputs found
Epicardial echocardiography
The technique described in this thesis will be referred to as "epicardial echocardiography".
The addition "intraoperative" is unnecessary, since "epicardial" presumes
operative access to the heart. If the transducer is applied to the aorta or other
great vessels after a median sternotomy, it would be more correctly to refer to the
technique as "epivascular echography". However, for simplicity, this term will
only be used if the transducer is applied to the descending thoracic and abdominal
aorta after lateral thoracotomy or thoraco-abdominal incisions.
The technique where the transducer is introduced into the esophagus during the
operation will be referred to as "intraoperative esophageal echocardiography".4
The traditional approach of echocardiography, by placing the transducer upon the
chest, will be referred to as "precordial" or "transthoracic echocardiography"
Initial results of combined anterior mitral leaflet extension and myectomy in patients with obstructive hypertrophic cardiomyopathy
Objectives. The purpose of this study was to describe the clinical and functional results of combined anterior mitral leaflet extension and myectomy in patients with hypertrophic obstructive cardiomyopathy. Background. Septal myectomy is the most commonly performed surgical procedure in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction. Because of the role of the mitral valve in creating the outflow tract gradient, mitral valve replacement or plication is performed in selected cases in combination with myectomy, often with better hemodynamic results than those of myectomy alone. Mitral valve leaflet extension, in which a glutaraldehyde-preserved autologous pericardial patch is used to enlarge the mitral valve along its horizontal axis, is a novel surgical approach in patients with hypertrophic obstructive cardiomyopathy. Methods. Eight patients with hypertrophic obstructive cardiomyopathy were treated with mitral leaflet extension and myectomy. Preoperative and postoperative data (New York Heart Association functional class, number of drugs prescribed, width of the interventricular septum, severity of mitral valve regurgitation, severity of systolic anterior motion of the mitral valve and outflow tract gradient) were compared with those of 12 patients undergoing myectomy alone. Results. Preoperative evaluation demonstrated that mitral regurgitation and systolic anterior motion of the mitral valve were more severe in the group undergoing mitral valve extension (p < 0.001 and p < 0.05, respectively). There were no deaths associated with either surgical procedure. Two patients, both treated by myectomy alone, died during the follow-up period. Postoperatively, patients treated with mitral valve extension had less mitral regurgitation (p < 0.005), less residual systolic anterior motion (p < 0.01), greater improvement in functional class (p = 0.05) and greater reduction in the number of drugs (p < 0.005) and in septal thickness (p < 0.05). Conclusions. Mitral leaflet extension in combination with myectomy is a promising new surgical approach that may provide superior results to those of myectomy alone. Further studies are needed to determine the clinical value of this procedure
Human tissue valves in aortic position: determinants of reoperation and valve regurgitation
BACKGROUND: Human tissue valves for aortic valve replacement have a
limited durability that is influenced by interrelated determinants.
Hierarchical linear modeling was used to analyze the relation between
these determinants of durability and valve regurgitation measured by
serial echocardiography. METHODS AND RESULTS: In adult patients, 218
cryopreserved aortic allografts were implanted with the subcoronary (85)
or the root replacement technique (133), and 81 patients had root
replacement with a pulmonary autograft. Mean follow-up was 4.2 years (SD
2.7; range, 0 to 10.5). Patient age, operator experience with subcoronary
implantation, and allograft diameter were independent predictors for
reoperation. With repeated color Doppler echocardiography, the severity of
aortic regurgitation was assessed by the jet length method and the jet
diameter ratio. Multilevel hierarchical linear modeling was used to
estimate initial aortic regurgitation (intercept), its change over time
(slope), and the effect of 11 potential determinants of durability on
aortic regurgitation. With the jet length method, the intercept was 0.94
grade and the slope was 0.11 grade per year. With the jet diameter ratio,
the intercept was 0.34 and the annual increase was 0.01. Subcoronary
implanted valves had more initial aortic regurgitation, but progression of
aortic valve regurgitation did not differ from root replacement. At
midterm follow-up, recipient age <40 years was the only independent
predictor of aortic regurgitation. CONCLUSIONS: Subcoronary implantation
has a learning curve, resulting in more initial aortic regurgitation and
early reoperation compared with root replacement. In both techniques,
progression of aortic regurgitation over time is small but accelerated in
young adults
Does the pulmonary autograft in the aortic position in adults increase in diameter? An echocardiographic study
Prognosis after aortic valve replacement with a bioprosthesis: predictions based on meta-analysis and microsimulation
BACKGROUND: Bioprostheses are widely used as an aortic valve substitute,
but knowledge about prognosis is still incomplete. The purpose of this
study was to provide insight into the age-related life expectancy and
actual risks of reoperation and valve-related events of patients after
aortic valve replacement with a porcine bioprosthesis. METHODS AND
RESULTS: We conducted a meta-analysis of 9 selected reports on stented
porcine bioprostheses, including 5837 patients with a total follow-up of
31 874 patient-years. The annual rates of valve thrombosis,
thromboembolism, hemorrhage, and nonstructural dysfunction were 0.03%,
0.87%, 0.38%, and 0.38%, respectively. The annual rate of endocarditis was
estimated at 0.68% for >6 months of implantat
Subcoronary implantation or aortic root replacement for human tissue valves: Sufficient data to prefer either technique?
The aortic root replacement technique with aortic allograft or pulmonary autograft might be superior to the subcoronary allograft implantation technique with regard to aortic regurgitation. We explored the influence of the learning process on the incidence of reoperation and the severity of postoperative aortic regurgitation as assessed by color Doppler echocardiography. The subcoronary implantation technique was used in 81 patients, and root replacement was done in 63 patients. The first 30 patients of each group were considered as the surgeons' learning curve. Reoperations were more common in the subcoronary implantation group. After exclusion of early reoperations, the median regurgitation score based on echocardiographic examination was 0.22 in the first 30 patients from the subcoronary implantation group and 0.14 in the root replacement group. The subsequent patients from these groups had regurgitation scores of 0.20 and 0.17, respectively. Statistical analysis of these data showed no significant difference. This interim report suggests that the learning curve for the surgical procedure and the grouping of echocardiographic data influence the interpretation of follow-up studies. The superiority of either technique with regard to aortic regurgitation has yet to be proved
Baseline MDCT findings after prosthetic heart valve implantation provide important complementary information to echocardiography for follow-up purposes
Objectives: Recent studies have proposed additional multidetector-row CT (MDCT) for prosthetic heart valve (PHV) dysfunction. References to discriminate physiological from pathological conditions early after implantation are lacking. We present baseline MDCT findings of PHVs 6 weeks post implantation. Methods: Patients were prospectively enrolled and TTE was performed according to clinical guidelines. 256-MDCT images were systematically assessed for leaflet excursions, image quality, valve-related artefacts, and pathological and additional findings. Results: Forty-six patients were included comprising 33 mechanical and 16 biological PHVs. Overall, MDCT image quality was good and relevant regions remained reliably assessable despite mild-moderate PHV-artefacts. MDCT detected three unexpected valve-related pathology cases: (1) prominent subprosthetic tissue, (2) pseudoaneurysm and (3) extensive pseudoaneurysms and valve dehiscence. The latter patient required valve surgery to be redone. TTE only showed trace periprosthetic regurgitation, and no abnormalities in the other cases. Additional findings were: tilted aortic PHV position (n = 3), pericardial haematoma (n = 3) and pericardial effusion (n = 3). Periaortic induration was present in 33/40 (83 %) aortic valve patients. Conclusions: MDCT allowed evaluation of relevant PHV regions in all valves, revealed baseline postsurgical findings and, despite normal TTE findings, detected three cases of unexpected, clinically relevant pathology. Key Points: • Postoperative MDCT presents baseline morphology relevant for prosthetic valve follow-up. • 83 % of patients show periaortic induration 6 weeks after aortic valve replacement. • MDCT detected three cases of clinically relevant pathology not found with TTE. • Valve dehiscence detection by MDCT required redo valve surgery in one patient. • MDCT is a suitable and complementary imaging tool for follow-up purposes
Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease
BACKGROUND: The recent recognition that coronary-artery stenting has improved the short- and long-term outcomes of patients treated with angioplasty has made it necessary to reevaluate the relative benefits of bypass surgery and percutaneous interventions in patients with multivessel disease. METHODS: A total of 1205 patients were randomly assigned to undergo stent implantation or bypass surgery when a cardiac surgeon and an interventional cardiologist agreed that the same extent of revascularization could be achieved by either technique. The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events at one year. The costs of hospital resources used were also determined. RESULTS: At one year, there was no significant difference between the two groups in terms of the rates of death, stroke, or myocardial infarction. Among patients who survived without a stroke or a myocardial infarction, 16.8 percent of those in the stenting group underwent a second revascularization, as compared with 3.5 percent of those in the surgery group. The rate of event-free survival at one year was 73.8 percent among the patients who received stents and 87.8 percent among those who underwent bypass surgery (P<0.001 by the log-rank test). The costs for the initial procedure were 2,973 per patient. CONCLUSION: As measured one year after the procedure, coronary stenting for multivessel disease is less expensive than bypass surgery and offers the same degree of protection against death, stroke, and myocardial infarction. However, stenting is associated with a greater need for repeated revascularization
Complicaties kort na percutane transluminale angioplastiek of na coronariachirurgie bij 183 vergelijkbare patienten met een meervatscoronaria-aandoening
Intraoperative high-dose dexamethasone for cardiac surgery
__Context:__ Prophylactic corticosteroids are often administered during cardiac surgery to attenuate the inflammatory response to cardiopulmonary bypass and surgical trauma; however, evidence that routine corticosteroid use can prevent major adverse events is lacking.
__Objective:__ To quantify the effect of intraoperative high-dose dexamethasone on the incidence of major adverse events in patients undergoing cardiac surgery.
__Design, Setting, and Participants:__ A multicenter, randomized, double-blind, placebocontrolled trial of 4494 patients aged 18 years or older undergoing cardiac surgery with cardiopulmonary bypass at 8 cardiac surgical centers in the Netherlands enrolled between April 13, 2006, and November 23, 2011.
__Intervention:__ Patients were randomly assigned to receive a single intraoperative dose of 1 mg/kg dexamethasone (n=2239) or placebo (n=2255).
__Main Outcome Measures:__ A composite of death, myocardial infarction, stroke, renal failure, or respiratory failure, within 30 days of randomization.
__Results:__ Of the 4494 patients who underwent randomization, 4482 (99.7%) could be evaluated for the primary outcome. A total of 157 patients (7.0%) in the dexamethasone group and 191 patients (8.5%) in the placebo group reached the primary study end point (relative risk, 0.83; 95% CI, 0.67-1.01; absolute risk reduction, -1.5%; 95% CI, -3.0% to 0.1%; P=.07). Dexamethasone was associated with reductions in postoperative infection, duration of postoperative mechanical ventilation, and lengths of intensive care unit and hospital stays. In contrast, dexamethasone was associated with higher postoperative glucose levels.
__Conclusion:__ In our trial of adults undergoing cardiac surgery, the use of intraoperative dexamethasone did not reduce the 30-day incidence of major adverse events compared with placebo