A Meta-Analysis of Cumulative Incidence of Hepatocellular Carcinoma After the Fontan Operation.

BACKGROUND: Hepatic complications are increasingly recognized after the Fontan operation. The development of hepatocellular carcinoma (HCC) is associated with high mortality when diagnosed, but its incidence and risk factors are poorly understood. We conducted a systematic review and meta-analysis of the cumulative incidence of HCC after Fontan and associated risk factors. METHODS: We searched PubMed, CINAHL, and MEDLINE databases for articles reporting the cumulative incidence of HCC after Fontan operation on March 21, 2023. A single-arm random effects meta-analysis was conducted to assess cumulative incidence at 10, 20, and 30 years after Fontan. Meta-analysis of the difference of the medians was used to assess the influence of risk factors on the development of HCC. RESULTS: Four studies including a total of 1320 patients reported cumulative incidence. The cumulative incidence of HCC at 10, 20, and 30 years after Fontan was 0% (95% CI 0.00-0.01), 2% (0.01-0.06), and 7% (0.03-0.17) respectively. Seven studies including 6,250 patients reported overall incidence of HCC and associated risk factors. At a median 18.4 (IQR 11.9-24.9) years of follow-up, incidence of HCC was 2% (0.01-0.04). Only use of anticoagulation was associated with a lower risk of HCC (RR 0.3, 95% CI 0.1-0.88). DISCUSSION: By 30 years after Fontan, cumulative incidence of HCC is high (7%). Risk of HCC development prior to 10 years post-Fontan is low (0%), though the decision to defer HCC surveillance in this period may require future investigation based on larger studies. Screening with ultrasound every 6 months starting 20 years post-Fontan is reasonable, however, further research regarding timing, cost-effectiveness, additional risk factors associated with HCC risk, and different screening modalities is required.

Transcatheter mitral valve in ring, hazards of long anterior mitral leaflet and 3-dimensional rings.

OBJECTIVES: The purpose of this study was to define anterior mitral leaflet (AML) length and mitral ring characteristics associated with LVOT obstruction and PVL following MViR. BACKGROUND: Transcatheter Mitral Valve in Ring (MViR) procedural complications including parvalvular leak (PVL) and left ventricular outflow tract (LVOT) obstruction are frequent. METHODS: Clinical records, computer tomographic scans (CTs) and echocardiograms of consecutive MViR patients were retrospectively reviewed for anterior mitral leaflet length, CT-simulated neoLVOT, and aortomitral angle among patients with and without MViR-induced LVOT obstruction. Acute and 1-year outcomes are described. RESULTS: Twenty-two patients underwent MViR. Technical success was achieved in 13/22 (57.1%) patients, limited by paravalvular regurgitation requiring second transcatheter heart valves (THVs) in seven patients. Second valves were needed in 6/11 (54.5%) patients with 3-dimensional rings but 1/11 (9.1%, p = .06) of patients with planar rings. Procedure success at 30 days was achieved in 20/22 (90.9%) patients. There were no procedural, in-hospital, or 30-day deaths. Two patients developed significant LVOT obstruction, one managed with urgent surgery and one with elective alcohol septal ablation. Anterior mitral leaflets were longer among the two patients with LVOT obstruction than the 20 patients who did not develop LVOT obstruction when measured by TEE (30 mm vs. 21 mm, p = .009) or by CT (29 mm vs. 22 mm, p = .026). CONCLUSIONS: AML >25 mm increases the risk of MViR induced LVOT obstruction. PVL is common, particularly in 3-dimensional rings which can be managed with a second THV.

Evaluation of new generation loop recorders placed during surgical ablation for atrial fibrillation.

BACKGROUND: Current postsurgical atrial fibrillation (AF) ablation guidelines encourage serial rhythm evaluation; however, traditional Holter monitoring may be cumbersome for patients and yield limited data. An implantable loop recorder (LR) may provide increased data on the incidence of postablation arrhythmias. We sought to evaluate the use of a new generation LR implanted during surgical AF ablation. METHODS: A retrospective analysis was performed on adult patients undergoing surgical AF ablation. All patients had subcutaneous placement of a LR. Data were collected on patient demographics, concomitant surgical procedures, complications, loop recorder extraction, and additional arrhythmia interventions. RESULTS: Thirty-one patients underwent surgical AF ablation with intraoperative placement of a LR during the study period. The median age was 71 and the majority had long-standing persistent AF. Mitral and aortic valve pathology was the most common reason for concomitant operations. Four devices were explanted prior to the completion of follow-up due to high AF burdens detected by the LR requiring catheter ablation or pacemaker placement. A 100% correlation between in-clinic rhythm detected by the LR and electrocardiogram was observed. No infectious complications, device malfunctions, or deaths occurred. CONCLUSIONS: LRs placed intraoperatively during surgical ablation of AF are feasible and with nominal, if any, complications. More comprehensive rhythm analysis may aid with determination of operative success and the need for additional intervention or cessation of antiarrhythmic or anticoagulant medications.

Double freestyle valve replacement in a patient with a prior Ross procedure.

Following a Ross procedure, patients may require reintervention for valvular stenosis or insufficiency of either the pulmonary autograft or the pulmonary homograft. Herein is reported a double use of the Medtronic Freestyle stentless bioprosthesis in a patient who previously had undergone a Ross procedure.

Impact of a focused review course in cardiovascular and thoracic surgery on test performance.

Background: The Core Curriculum Review Course in Cardiovascular and Thoracic Surgery is a 4-day educational program consisting of 77 didactic lectures that provide a comprehensive review of the material required for surgeons preparing for the American Board of Thoracic Surgery competency written examination. The lectures are supplemented with a written syllabus and interactive audience participation system. We sought to determine whether participation in this course could improve participants' performance on a cardiothoracic subject-based test. Methods: Sixty-five participants attended the 2018 course. Before beginning the course lectures, a multiple-choice pretest consisting of 77 questions was administered via mobile application to gauge the participants' baseline knowledge. A second multiple-choice posttest was made available beginning 7 weeks after the course, also by mobile application. Results: Twenty-nine participants completed both the pretest and the posttest. The median pretest score was 47% (36 of 77 correct answers). The median posttest score was 61% (47 of 77 correct answers), representing an increase of 14%. The Wilcoxon signed-rank test indicated a significant difference between the pretest and posttest scores (z = -4.36; P = .00). Overall, 25 participants (86%) improved their posttest score. Conclusions: The core curriculum review course was successful in improving participants' performance on the course tests, indicating that the participants' fund of knowledge was likely increased by attendance at the program. Additional strategies should be considered to address particular areas of study both for individual participants and for residents currently in training.

Vitamin D supplementation protects against reductions in plasma 25-hydroxyvitamin D induced by open-heart surgery: Assess-d trial.

Low vitamin D (serum or plasma 25-hydroxyvitamin D (25(OH)D)) is a global pandemic and associates with a greater prevalence in all-cause and cardiovascular mortality and morbidity. Open-heart surgery is a form of acute stress that decreases circulating 25(OH)D concentrations and exacerbates the preponderance of low vitamin D in a patient population already characterized by low levels. Although supplemental vitamin D increases 25(OH)D, it is unknown if supplemental vitamin D can overcome the decreases in circulating 25(OH)D induced by open-heart surgery. We sought to identify if supplemental vitamin D protects against the acute decrease in plasma 25(OH)D propagated by open-heart surgery during perioperative care. Participants undergoing open-heart surgery were randomly assigned (double-blind) to one of two groups: (a) vitamin D (n = 75; cholecalciferol, 50,000 IU/dose) or (b) placebo (n = 75). Participants received supplements on three separate occasions: orally the evening before surgery and either orally or per nasogastric tube on postoperative days 1 and 2. Plasma 25(OH)D concentrations were measured at baseline (the day before surgery and before the first supplement bolus), after surgery on postoperative days 1, 2, 3, and 4, at hospital discharge (5-8 days after surgery), and at an elective outpatient follow-up visit at 6 months. Supplemental vitamin D abolished the acute decrease in 25(OH)D induced by open-heart surgery during postoperative care. Moreover, plasma 25(OH)D gradually increased from baseline to day 3 and remained significantly increased thereafter but plateaued to discharge with supplemental vitamin D. We conclude that perioperative vitamin D supplementation protects against the immediate decrease in plasma 25(OH)D induced by open-heart surgery. ClinicalTrials.gov Identifier: NCT02460211.

Cardiothoracic Surgery Residency Training in Surgical Ablation for Atrial Fibrillation.

BACKGROUND: As no standardized curriculum exists for training cardiothoracic surgery residents in surgical ablation for atrial fibrillation there is potential for variation in operative technique, patient selection, and overall application. Thus we sought to assess the exposure of current residents in order to identify areas for improvement in their education. METHODS: A survey was emailed to residents inquiring about their training experience in surgical ablation for atrial fibrillation. Residents were asked about case volume, procedural variety, and guideline-based clinical scenarios where they felt ablation would be appropriate. Residents were also queried about their abilities to perform various lesion sets and overall satisfaction with training. RESULTS: The respondents performed a median of five cases during training with pulmonary vein isolation the most common lesion set. Seventy seven percent of residents are unable to independently perform a bi-atrial (Cox-Maze IV) lesion set. Residents are neutral regarding their satisfaction with training in surgical ablation for atrial fibrillation. CONCLUSIONS: The findings of low case volume, incomplete lesion set use, and lack of training satisfaction suggests residents are being insufficiently exposed to surgical ablation of atrial fibrillation. These findings should inform educators on the importance of a more thorough experience during training given the increasing prevalence of atrial fibrillation and the need for appropriate and durable surgical intervention.

Transcatheter Aortic Valve-in-Valve Replacement for Degenerated Stentless Bioprosthetic Aortic Valves: Results of a Multicenter Retrospective Analysis.

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) for stentless bioprosthetic aortic valves (SBAVs) and to identify predictors of adverse events. BACKGROUND: ViV TAVR in SBAVs is associated with unique technical challenges and risks. METHODS: Clinical records and computer tomographic scans were retrospectively reviewed for procedural complications, predictors of coronary obstruction, mortality, and echocardiographic results. RESULTS: Among 66 SBAV patients undergoing ViV TAVR, mortality was 2 of 66 patients (3.0%) at 30 days and 5 of 52 patients (9.6%) at 1 year. At 1 year, left ventricular end-systolic dimension was decreased versus baseline (median [interquartile range (IQR)]: 3.0 [2.6 to 3.6] cm vs. 3.7 [3.2 to 4.4] cm; p < 0.001). Coronary occlusion in 6 of 66 procedures (9.1%) resulted in myocardial infarction in 2 of 66 procedures (3.0%). Predictors of coronary occlusion included subcoronary implant technique compared with full root replacement (6 of 31, 19.4% vs. 0 of 28, 0%; p = 0.01), short simulated radial valve-to-coronary distance (median [IQR]: 3.4 [0.0 to 4.6] mm vs. 4.6 [3.2 to 6.2] mm; p = 0.016), and low coronary height (7.8 [5.8 to 10.0] mm vs. 11.6 [8.7 to 13.9] mm; p = 0.003). Coronary arteries originated <10 mm above the valve leaflets in 34 of 97 unobstructed coronary arteries (35.1%). CONCLUSIONS: TAVR in SBAVs is frequently associated with high-risk coronary anatomy but can be performed with a low risk of death and myocardial infarction, resulting in favorable ventricular remodeling. A subcoronary surgical approach is associated with an increased risk of coronary obstruction.

Concomitant surgical treatment of coronary artery disease and coarctation of the aorta in a patient with dextrocardia.

We report the case of a 43-year-old woman with severe coronary artery disease, coarctation of the aorta and dextrocardia. Concomitant repair was achieved by coronary artery bypass grafting and ascending-descending bypass of the proximal descending thoracic aorta.

Freedom from structural valve deterioration among patients aged < or = 60 years undergoing Freestyle stentless aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Certain theoretical arguments suggest that a stentless bioprosthetic valve may be less subject to calcification and degeneration compared to an equivalent stented bioprosthesis. The study aim was to define the long-term clinical outcomes, including freedom from structural valve deterioration (SVD), among relatively younger patients after aortic valve replacement (AVR) with the Freestyle aortic bioprosthesis. METHODS: A total of 725 patients at eight study sites underwent AVR with the Freestyle stentless aortic bioprosthesis. Of these patients, 57 (7.9%) were aged < or = 60 years at the time of surgery. All clinical data were recorded prospectively. RESULTS: The total follow up for the group was 4,900 patient-years; the mean follow up per patient was 6.8 +/- 3.6 years; median 7.2 years; range: 0 to 13.3 years). Survival at 12 years was 65.0 +/- 11.6% for patients aged < or = 60 years at implant, and 33.1 +/- 5.3% for those aged > or = 61 years. Freedom from cardiac death was 94.6 +/- 6.6% and 70.7 +/- 7.5%, respectively. Freedom from SVD at 12 years was 92.4 +/- 8.0% for patients aged < or = 60 years at implant, and 92.3 +/- 5.0% for those aged > or = 61 years (p = 0.58). There was no significant difference in freedom from reoperation at 12 years between the younger and older age groups (p = 0.16). CONCLUSION: The Freestyle stentless aortic bioprosthesis was associated with excellent clinical outcomes through 12 years of follow up. Freedom from cardiac death was excellent. Measures of bioprosthesis durability remained outstanding through 12 years, with no difference in freedom from SVD or from reoperation between patients aged < or = 60 years and those aged > or = 61 years at the time of implant. Inasmuch as valve durability may influence decisions between a tissue and a mechanical valve in younger patients, these data help to support use of the Freestyle valve in patients aged < or = 60 years.

Radiopaque Marker Addition During Aortic Root Replacement With the Use of a Freestyle Porcine Bioprosthesis.

Aortic root replacement is indicated for aortic root aneurysm, small aortic root, and most root abscesses. This report describes the placement of a radiopaque marker during aortic root replacement using a Freestyle porcine bioprosthesis. This marker is a useful landmark during fluoroscopy for transcatheter valve-in-valve aortic valve replacement in the event of bioprosthesis degeneration.

Acute on chronic pulmonary autograft dissection.

We report a case of combined acute and chronic dissection limited to the pulmonary autograft 10 years after a Ross procedure, managed by replacement with a stentless porcine bioprosthesis. Implications for timing and technique of reintervention for pulmonary autograft dilatation are discussed.

Comparing velour versus silicone interfaces at the driveline exit site of HeartMate II devices: infection rates, histopathology, and ultrastructural aspects.

BACKGROUND: Driveline exit site (DLES) infection is a major complication of ventricular assist devices (VADs). Differences in the sheath material interfacing with exit site tissue appear to affect healing time and infection risk more than site hygiene, but the mechanistic basis for this is not clear. METHODS: Health record data from Utah Artificial Heart Program patients with HeartMate II (HMII) devices implanted from 2008 to 2012 were retrospectively reviewed, with particular attention to interface type, incorporation (healing) time, and infections. Tissue samples from the DLES were collected at the time of VAD removal in a small subset. These samples were examined by routine histology and environmental scanning electron microscopy (ESEM). RESULTS: Among 57 patients with sufficient data, 15 had velour interfaces and 42 had silicone. Indications for and duration of support were similar between the groups. The silicone group had shorter incorporation time (45 ±22 vs. 56 ±34 days, P=.17) and fewer DLES infections (20% vs. 1.7%, P=.026, for patient infections and 0.0340 vs. 0.166, P=.16, for infections per patient-year). Tissues from five patients, three with velour, were examined. Velour interfaces demonstrated more hyperkeratosis, hypergranulosis, and dermal inflammation. By ESEM, the silicone driveline tracts appeared relatively smooth and flat, whereas the velour interface samples were irregular with deep fissures and globular material adhering to the surface. CONCLUSIONS: Using the silicone portion of the HMII driveline at the DLES was associated with fewer infections and a trend toward faster healing in this small retrospective series. Whether the intriguing microscopic differences directly account for this needs further study on a larger scale.

Atheroembolism in cardiac surgery.

BACKGROUND: Atheroembolism is a recognized complication of cardiac surgery, but its incidence and various outcomes have not been completely described. A retrospective study was undertaken to better characterize the syndrome. METHODS: Records of 49,377 autopsies and surgical specimens from the Johns Hopkins Hospital between 1973 and 1995 were reviewed. Three hundred twenty-seven patients (0.7%) had an identifiable atheroembolism on histologic examination. Of these patients, 29 (0.2%) had undergone a cardiac surgical procedure within 30 days of autopsy or surgical resection. Patient charts and pathology specimens were reviewed for operative findings, postoperative outcomes, and histology. RESULTS: Six of the 29 patients (21%) had atheroembolism to the heart, 7 patients (24%) had embolism to the central nervous system, 19 patients (66%) had embolism to the gastrointestinal tract, 14 patients (48%) had embolism to one or both kidneys, and 5 patients (17%) had embolism to a lower extremity. Sixteen patients (55%) had atheroembolism in two or more areas. In 6 patients (21%), death was directly attributable to atheroembolism, including intraoperative cardiac failure from coronary embolism (n = 3), massive stroke (n = 2), and extensive gastrointestinal embolization (n = 1). CONCLUSIONS: Atheroembolism in cardiac surgery has a broad spectrum of clinical presentations, including devastating injuries and death. Although the true incidence is probably underestimated in this retrospective study, the high attendant mortality and morbidity of atheroembolism have been documented. Improvements in outcome are likely to be associated with preoperative identification of patients at high risk, modifications of perfusion technique, and interventions to minimize secondary thrombosis and progressive organ ischemia.

Postesophagectomy morbidity, mortality, and length of hospital stay after preoperative chemoradiation therapy.

BACKGROUND: Data suggest that preoperative chemoradiation improves survival in patients with stage II and III esophageal tumors. Whether preoperative therapy increases postesophagectomy morbidity and mortality has not been determined. This study evaluates our postoperative results after chemoradiation therapy. METHODS: From 1989 through 1998, 120 consecutive patients underwent chemoradiation therapy followed by esophagectomy at our institution. The medical records for these patients were reviewed to determine patient age, sex, race, cell type, operative technique, complications, deaths, and length of hospital stay (LOS). RESULTS: There were 106 (88%) men and 14 (12%) women with a mean age of 58 (32 to 77) years. White patients predominated (114 of 120, 95%); 98 (82%) had adenocarcinoma and 22 (18%) had squamous cell carcinoma. Operative technique was transhiatal in 91 (76%) patients, three-incision in 23 (19%), Ivor-Lewis in 4 (3%), and thoracoabdominal in 2 (2%). There was 1 death. Complications developed in 44 (37%) patients; 59% (13 of 22) of squamous cell carcinoma patients and 32% (31 of 98) of adenocarcinoma patients developed complications. Respiratory complications occurred in 32% (7 of 22) of squamous cell carcinoma patients and in 3% (3 of 98) of adenocarcinoma patients. Mean length of stay after surgery was 15 days (range 7 to 163). CONCLUSIONS: Postesophagectomy results after chemoradiation therapy are comparable to those reported after esophagectomy alone. Squamous cell carcinoma patients are nearly twice as likely to develop postoperative complications and are more likely to have respiratory complications than adenocarcinoma patients.

Cholecystectomy, liver resection, and pylorus-preserving pancreaticoduodenectomy for gallbladder cancer: report of five cases.

Carcinoma of the gallbladder is an uncommon yet highly malignant disease with a poor overall prognosis. Surgical resection offers the only hope for cure in patients with this type of cancer, but resection is often impossible because of advanced disease at the time of presentation. Patients with locally advanced gallbladder cancer, however, may occasionally be amenable to management by adding pancreaticoduodenectomy to cholecystectomy and liver resection. A retrospective review of patient records at the Johns Hopkins Hospital identified five patients with gallbladder cancer with peripancreatic lymph node involvement, who were treated by surgical resection including pancreaticoduodenectomy. The preoperative evaluation, operative technique, pathologic findings, and outcome were reviewed for each patient. Follow-up was obtained via clinic visit or telephone contact. All five patients underwent resection of the gallbladder cancer with an operation that included pylorus-preserving pancreaticoduodenectomy to remove the peripancreatic lymph nodes. In addition, four of the five patients underwent a nonanatomic liver resection. There were no in-hospital deaths. Two patients had postoperative complications; one had persistent drainage from a T-tube site and one had an anastomotic leak from the hepaticojejunostomy. Four patients have died of recurrent tumor during follow-up at intervals ranging from 11 months to 23 months. The fifth patient is alive and free of clinical disease at 42 months after operation. Carcinoma of the gallbladder is a highly malignant disease that is often not amenable to surgical cure. There is a select group of patients, however, in whom adding a pylorus-preserving pancreaticoduodenectomy can result in a potentially curative operation by removing extensive regional spread to the peripancreatic lymph nodes.

Black pigmented aortic valve and sinus of Valsalva caused by life-long minocycline therapy.

Minocycline, a derivative of tetracycline, is a broad-spectrum antibiotic used in the treatment of various infections. Black discolouration of the skin, teeth, bones and the thyroid gland are sequelae of long-term minocycline therapy. We report an unusual case of minocycline-induced pigmentation of the aortic valve and sinuses of Valsalva.

Minimally invasive aortic valve replacement surgery through lower half sternotomy.

Less invasive approaches to aortic valve surgery frequently rely upon the development of new technology and instrumentation. While not suitable for every patient requiring an aortic valve procedure, these less invasive operations can offer certain clinical benefits and are becoming an important part of the modern cardiothoracic surgeon's skillset. A lower partial sternotomy approach provides excellent visualization of the operative field, efficient execution of the operation and many of the benefits of minimally invasive surgery. Importantly, the lower partial sternotomy requires no new or unusual instruments and presents a familiar view to the surgeon. The technique, therefore, lends itself well to being adapted and utilized quickly with a potentially shorter "learning curve" for maximal surgical flexibility and patient benefit.

Cardiac magnetic resonance imaging for perioperative evaluation of sternal eversion for pectus excavatum.

OBJECTIVES: Pectus excavatum is associated with varying degrees of exercise intolerance and symptomatology. Various forms of evaluation have been inconsistent in identifying objective data for correlation with symptoms. Cardiac magnetic resonance (CMR) imaging provides a promising method for delineating the anatomical and physiological components of pectus excavatum as well as measuring the results of surgical repair. METHODS: Six patients with symptomatic pectus excavatum underwent preoperative evaluation with CMR. All patients had successful, uncomplicated repair of pectus excavatum using the sternal eversion technique. At the first postoperative visit, all patients underwent postoperative evaluation with CMR. Pre- and postoperative CMR measurements were compared for each patient. RESULTS: Preoperative CMR demonstrated evidence of anatomical and dynamical compression of the heart in all patients. After surgery, all patients showed improvement on postoperative CMR. Five of the 6 (83%) patients had complete relief of right ventricular compression, and 5 of the 6 (83%) patients had relief of left atrial compression. The degree of antero-posterior chest wall narrowing was also markedly improved, with an average postoperative vs preoperative Haller index of 3.2 (range, 2.7-3.8) vs 5.0 (range, 4.0-5.9). CONCLUSIONS: After surgical correction of pectus excavatum with the sternal eversion technique, CMR demonstrates improvement in both anatomical chest wall contour and cardiac performance. Sternal eversion provides the most complete anatomical correction and greatest relief of internal cardiac compression. We recommend CMR as the definitive modality for evaluation of patients with pectus excavatum, as this modality shows that the primary underlying physiological abnormality in pectus excavatum is cardiac compression.