Mapping Semaphorins and Netrins in the Pathogenesis of Human Thoracic Aortic Aneurysms.

Thoracic aortic aneurysm (TAA) is a complex life-threatening disease characterized by extensive extracellular matrix (ECM) fragmentation and persistent inflammation, culminating in a weakened aorta. Although evidence suggests defective canonical signaling pathways in TAA, the full spectrum of mechanisms contributing to TAA is poorly understood, therefore limiting the scope of drug-based treatment. Here, we used a sensitive RNA sequencing approach to profile the transcriptomic atlas of human TAA. Pathway analysis revealed upregulation of key matrix-degrading enzymes and inflammation coincident with the axonal guidance pathway. We uncovered their novel association with TAA and focused on the expression of Semaphorins and Netrins. Comprehensive analysis of this pathway showed that several members were differentially expressed in TAA compared to controls. Immunohistochemistry revealed that Semaphorin4D and its receptor PlexinB1, similar to Netrin-1 proteins were highly expressed in damaged areas of TAA tissues but faintly detected in the vessel wall of non-diseased sections. It should be considered that the current study is limited by its sample size and the use of internal thoracic artery as control for TAA for the sequencing dataset. Our data determines important neuronal regulators of vascular inflammatory events and suggest Netrins and Semaphorins as potential key contributors of ECM degradation in TAA.

Reengineering valve patients' postdischarge management for adapting to bundled payment models.

BACKGROUND: Bundled Payments for Care Improvement (BPCI) initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. Payment model 2 reimburses based on a target price for 90-day episode of care postprocedure. The challenge for valve patients is the historically high (>35%) 90-day readmission rate. We analyzed our institutional cardiac surgical service line adaptation to this initiative. METHODS: On May 1, 2015, we instituted a readmission reduction initiative (RRI) that included presurgical risk stratification, comprehensive predischarge planning, and standardized postdischarge management led by cardiac nurse practitioners (CNPs) who attempt to guide any postdischarge encounters (PDEs). A prospective database also was developed, accruing data on all cardiac surgery patients discharged after RRI initiation. We analyzed detailed PDEs for all valve patients with complete 30-day follow-up through November 2015. RESULTS: Patients included 219 surgical patients and 126 transcatheter patients. Sixty-four patients had 79 PDEs. Of these 79 PDEs, 46 (58.2%) were guided by CNPs. PDEs were due to fluid overload/effusion (21, 27%), arrhythmia (17, 22%), bleeding/thromboembolic events (13, 16%), and falls/somatic complaints (12, 15%). Thirty-day readmission rate was 10.1% (35/345). Patients with transcatheter aortic valve replacement had a higher rate of readmission than surgical patients (15.0% vs 6.9%), but were older with more comorbidities. The median readmission length of stay was 2.0 days (interquartile range 1.0-5.0 days). Compared with 2014, the 30-day readmission rate for BPCI decreased from 18% (44/248) to 11% (20/175), P = .05. CONCLUSIONS: Our reengineering of pre/postdischarge management of BPCI valve patients under tight CNP control has significantly reduced costly 30-day readmissions in this high-risk population.

Too Cold to Clot? Does Intraoperative Hypothermia Contribute to Bleeding After Aortic Surgery?

BACKGROUND: We determined the impact of intraoperative hypothermia on postoperative bleeding after thoracic aortic surgery. METHODS: We retrospectively analyzed 98 consecutive patients who underwent aortic surgery with deep hypothermic circulatory arrest between 2010 and 2014. We evaluated lowest temperature, absolute decrease in temperature, and rewarming rate. Univariate and multivariate regression were used to determine relationships between temperature, clinical characteristics, and measures of postoperative bleeding. RESULTS: The mean age of patients was 60.5 ± 15.1 years, with 64.3% male and 60% Caucasian. The lowest temperatures recorded were 13.5 ± 4.6°C at the bypass circuit. Change in hematocrit was associated with ethnicity, preoperative hematocrit, and rewarming rate. Chest tube output was associated with body mass index, preoperative platelet count, prior cardiac surgery, cardiopulmonary bypass (CPB) duration, intraoperative blood product transfusion, lowest surface temperature, and change in surface temperature. Postoperative packed red blood cell transfusion was associated with ejection fraction, chronic obstructive pulmonary disease (COPD), platelet count, partial thromboplastin time, CPB duration, and lowest blood temperature. Fresh frozen plasma transfusion correlated with COPD, CPB duration, and final blood temperature. Platelet transfusion correlated with body mass index and preoperative platelet count. Unplanned reoperation for bleeding was associated with final temperature and change in temperature. CONCLUSION: We found no consistent associations between intraoperative temperature and indicators of bleeding. Intraoperative cooling strategies should be based on optimal end-organ protection rather than fear of postoperative bleeding; rewarming strategies may ameliorate the risk of coagulopathy.

The use of the Risk Assessment and Prediction Tool in surgical patients in a bundled payment program.

OBJECTIVES: The purpose of this study was to evaluate the relationship between the Risk Assessment and Predictor Tool (RAPT) and patient discharge disposition in an institution participating in bundled payment program for total joint replacement, spine fusion and cardiac valve surgery patients. METHOD: Between April 2014 and April 2015, RAPT scores of 767 patients (535 primary unilateral total joint arthroplasty; 150 cardiac valve replacement; 82 spinal fusions) were prospectively captured. Total RAPT scores were grouped into three levels for risk of complications: <6 = 'high risk', between 6 and 9 = 'medium risk', and >9 = 'low risk' for discharge to a post-acute facility. Associations between RAPT categories and patient discharge to home versus any facility were conducted. Multivariate analysis was performed to determine if there was any correlation between RAPT score and discharge to any facility. RESULTS: 70.5% of total joint patients, 80.7% of cardiac valve surgery patients and 70.7% of spine surgery patients were discharged home rather than to a post-acute facility. RAPT risk categories were related to discharge disposition as 72% of those in the high risk group were discharged to a facility and 91% in the low risk group were discharged to home in the total joint replacement cohort. In the cardiac cohort, only 33% of the high risk group was discharged to a facility, and 94% of the low risk group was discharged to home. In the spinal fusion cohort, 60% of those in the high risk group were discharged to a facility and 86% in the low risk group were discharged to home. Multivariate analysis showed that being in the high risk category versus low risk category was significantly associated with substantially increased odds of discharge to a facility. CONCLUSION: The RAPT tool has shown the ability to predict discharge disposition for total joint and spine surgery patients, but not cardiac valve surgery patients, where the majority of patients in all categories were discharged home, at an institution participating in a bundled payment program. The ability to identify discharge disposition pre-operatively is valuable for improving care coordination, directing care resources and establishing and maintaining patient and family expectations.

Mechanical strength of aneurysmatic and dissected human thoracic aortas at different shear loading modes.

Rupture of aneurysms and acute dissection of the thoracic aorta are life-threatening events which affect tens of thousands of people per year. The underlying mechanisms remain unclear and the aortic wall is known to lose its structural integrity, which in turn affects its mechanical response to the loading conditions. Hence, research on such aortic diseases is an important area in biomechanics. The present study investigates the mechanical properties of aneurysmatic and dissected human thoracic aortas via triaxial shear and uniaxial tensile testing with a focus on the former. In particular, ultimate stress values from triaxial shear tests in different orientations regarding the aorta׳s orthotropic microstructure, and from uniaxial tensile tests in radial, circumferential and longitudinal directions were determined. In total, 16 human thoracic aortas were investigated from which it is evident that the aortic media has much stronger resistance to rupture under 'out-of-plane' than under 'in-plane' shear loadings. Under different shear loadings the aortic tissues revealed anisotropic failure properties with higher ultimate shear stresses and amounts of shear in the longitudinal than in the circumferential direction. Furthermore, the aortic media decreased its tensile strength as follows: circumferential direction >longitudinaldirection> radial direction. Anisotropic and nonlinear tissue properties are apparent from the experimental data. The results clearly showed interspecimen differences influenced by the anamnesis of the donors such as aortic diseases or connective tissue disorders, e.g., dissected specimens exhibited on average a markedly lower mechanical strength than aneurysmatic specimens. The rupture data based on the combination of triaxial shear and uniaxial extension testing are unique and build a good basis for developing a 3D failure criterion of diseased human thoracic aortic media. This is a step forward to more realistic modeling of mechanically induced tissue failure i.e. rupture of aneurysms or progression of aortic dissections.

Operative Strategies and Outcomes in Type A Aortic Dissection After the Enactment of a Multidisciplinary Aortic Surgery Team.

OBJECTIVE: The purpose of this study was to compare operative strategies and patient outcomes in acute type A aortic dissection (ATAAD) repairs before and after the implementation of a multidisciplinary aortic surgery team. METHODS: Between May 2005 and July 2014, 101 patients underwent ATAAD repair at our institution. A dedicated multidisciplinary aortic surgery team (experienced aortic surgeon, perfusionists, cardiac anesthesiologists, nurses, and radiologists) was formed in 2010. We retrospectively compared ATAAD repair outcomes in patients before (2005-2009, N = 39) and after (2010-2014, N = 62) implementation of our program. Expected operative mortality was calculated using the International Registry of Acute Aortic Dissection preoperative predictive model. RESULTS: This study demonstrated a significant reduction in operative mortality after implementation of the aortic surgery program (30.8% vs. 9.7%; P = 0.014). There was also an increase in the complexity of surgical technique and perfusion strategies with fewer postoperative complications related to respiratory (P < 0.0001) and renal failure (P = 0.034). Baseline demographics were similar, and there was no statistically significant difference in International Registry of Acute Aortic Dissection predictive variables between the 2 groups. However, there was a 3.5-fold reduction in the observed-to-expected (O/E) operative mortality ratio. There was a 50% increase in volume with a significant number of patients being admitted directly to our aortic center for ATAAD repair, thus avoiding delay in operation related to transfers from a secondary hospital. CONCLUSIONS: Patient outcomes are improved when the surgical treatment of ATAAD is managed by a high-volume multidisciplinary aortic surgery team.

Blood conservation strategies can be applied safely to high-risk complex aortic surgery.

OBJECTIVE: The present study aimed to evaluate the effect of blood conservation strategies on patient outcomes after aortic surgery. DESIGN: Retrospective cohort analysis of prospective data. SETTING: University hospital. PARTICIPANTS: Patients undergoing thoracic aortic surgery. INTERVENTIONS: One hundred thirty-two consecutive high-risk patients (mean EuroSCORE 10.4%) underwent thoracic aortic aneurysm or dissection repair from January 2010 to September 2011. A blood conservation strategy (BCS) focused on limitation of hemodilution and tolerance of perioperative anemia was used in 57 patients (43.2%); the remaining 75 (56.8%) patients were managed by traditional methods. Mortality, major complications, and red blood cell transfusion requirements were assessed. Independent risk factors for clinical outcomes were determined by multivariate analyses. MEASUREMENTS AND MAIN RESULTS: Hospital mortality was 9.8% (13 of 132). Lower preoperative hemoglobin was an independent predictor of mortality (p<0.01, odds ratio [OR] 1.7). Major complications were associated with perioperative transfusion: 0% complication rate in patients receiving<2 units of packed red blood cells versus 32.3% (20 of 62) in patients receiving ≥2 units. The blood conservation strategy had no significant impact on mortality (p = 0.4) or major complications (p = 0.9) despite the blood conservation patients having a higher incidence of aortic dissection and urgent/emergent procedures and lower preoperative and discharge hemoglobin. In patients with aortic aneurysms, BCS patients received 1.5 fewer units of red blood cells (58% reduction) than non-BCS patients (p = 0.01). Independent risk factors for transfusion were lower preoperative hemoglobin (p<0.01, OR 1.5) and lack of BCS (p = 0.02, OR 3.6). CONCLUSIONS: Clinical practice guidelines for blood conservation should be considered for high-risk complex aortic surgery patients.

The Chronobiology of Stanford Type A Aortic Dissections: A Comparison of Northern versus Southern Hemispheres.

BACKGROUND: Seasonal variations of Stanford Type A dissections (STADs) have been previously described in the Northern Hemisphere (NH). This study sought to determine if these variation are mirrored in the Southern Hemisphere (SH). METHODS: Data from patients treated surgically for STADs were retrospectively obtained from existing administrative and clinical databases from NH and SH sites. Data points of interest included age, sex, date of dissection, and 30-day mortality. The dates of dissections (independent of year) were then organized by season. RESULTS: A total of 1418 patients were identified (729 NH and 689 SH) with complete data available for 1415; 896 patients were male with a mean age was 61 ± 14 years, and the overall 30-day mortality was 17.3%. Comparison of NH and SH on a month-to-month basis demonstrated a 6-month phase shift and a significant difference by season, with STADs occurring predominantly in the winter and least in the summer. Decomposition of the monthly incidence using Fourier analysis revealed the phase shift of the primary harmonic to be -21.9 and 169.8 degrees (days), respectively, for NH and SH. The resultant 191.7 day difference did not exactly correspond to the anticipated 6-month difference but was compatible with the original hypothesis. CONCLUSION: Chronobiology plays a role in the occurrence of STADs with the highest occurrence in the winter months independent of the hemisphere. Season is not the predominant reason why aortas dissect, but for patients at risk, the increase in systemic vascular resistance during the winter months may account for the seasonal variations seen.

Systolic anterior motion of the mitral valve: a 30-year perspective.

OBJECTIVE: Systolic anterior motion (SAM) can occur after mitral valve repair (MVr), most frequently in patients with degenerative valve disease. Our initial observations (1981-1990) revealed that most patients with SAM can be successfully treated medically. Here the authors review the last 16 years of their experience with SAM after MVr. METHODS: Between January 1996 and October 2011, 1918 patients with degenerative mitral valve disease underwent MVr at our institution. We performed a retrospective analysis of SAM in this patient population. RESULTS: The incidence of SAM was 4.6% (89 of 1918) overall, 4.0% (77 of 1906) in patients who did not have SAM preoperatively (de novo). Compared with our previously published report, the incidence of SAM decreased from 6.4% to 4.0% (P = .03). Hospital mortality was 2.0% (38 of 1918) overall, 1.3% (14 of 1078) for isolated MVr. One patient with de novo SAM (1 of 77; 1.3%) died after emergency MVr. All patients with de novo SAM were successfully managed conservatively with intravenous fluids, α agonists, and/or ß blockers. A higher incidence of SAM was associated with a left ventricular ejection fraction greater than 60% (P = .01), posterior leaflet resection (P = .048), and hypertrophic obstructive cardiomyopathy (P < .01). The incidence of SAM was lower in patients who underwent device mitral annuloplasty with a semirigid posterior band compared with a complete ring (P = .03). CONCLUSIONS: In the more recent era, SAM occurs one-third less frequently after repair of degenerative mitral valve disease. Use of an incomplete annuloplasty band rather than a complete ring is associated with a lower incidence of SAM. The mainstay treatment of SAM continues to be medical management.

Long-term results of mitral valve repair with semi-rigid posterior band annuloplasty.

BACKGROUND AND AIM OF THE STUDY: Optimal repair of the mitral valve involves the implantation of an annuloplasty device to geometrically reshape and/or stabilize the annulus and improve long-term durability. It has been reported previously that trigone-to-trigone semi-rigid posterior band (PB) annuloplasty is associated with excellent short-term outcomes, physiologic motion of the anterior mitral annulus and leaflet, and lower postoperative transvalvular gradients compared to complete ring (CR) annuloplasty. The aim of this retrospective study was to compare the long-term effectiveness of PB and CR annuloplasty in patients with degenerative mitral valve regurgitation (MR). METHODS: Between 1993 and 2010, a total of 1,612 patients with degenerative MR underwent mitral valve repair (MVr) with either PB (n = 1,101) or CR (n = 511). Initially, CR was the annuloplasty device of choice, but after 2001 PB was preferred. A retrospective review of clinical and echocardiographic follow up was performed on these patients. The eight-year cumulative freedom from adverse events were determined by life-table analysis. RESULTS: Hospital mortality was 1.9% overall (n = 30/1612), but 1.3% (12/939) for isolated MVr, and 2.7% (18/673) for MVr with concomitant procedures (p = 0.04). Hospital mortality was similar for both PB (1.9%; 21/1101) and CR (1.8%; 9/511) (p = 0.8). The mean MR grade was reduced from 3.9 +/- 0.3 preoperatively to 0.6 +/- 0.9 at follow up using PB (p < 0.01), and from 3.9 +/- 0.4 to 0.9 +/- 0.9 using CR (p < 0.01). PB was associated with a similar long-term freedom from death (77 +/- 0.03% versus 83 +/- 0.02%; p = 0.4), reoperation (95 +/- 0.01% versus 92 +/- 0.01%; p = 0.06), and reoperation or recurrent severe MR (91 +/- 0.02% versus 92 +/- 0.01%; p = 0.7), and slightly greater freedom from valve-related complications compared to CR (91 +/- 0.02% versus 87 +/- 0.02%; p = 0.02). CONCLUSION: The long-term outcome of mitral valve annuloplasty with PB was comparable to that with CR for degenerative disease. Anterior annuloplasty was found to be unnecessary in this patient population.

Can the learning curve of totally endoscopic robotic mitral valve repair be short-circuited?

OBJECTIVE: A concern with the initiation of totally endoscopic robotic mitral valve repair (TERMR) programs has been the risk for the learning curve. To minimize this risk, we initiated a TERMR program with a defined team and structured learning approach before clinical implementation. METHODS: A dedicated team (two surgeons, one cardiac anesthesiologist, one perfusionist, and two nurses) was trained with clinical scenarios, simulations, wet laboratories, and "expert" observation for 3 months. This team then performed a series of TERMRs of varying complexity. RESULTS: Thirty-two isolated TERMRs were performed during the first programmatic year. All operations included mitral valve repair, left atrial appendage exclusion, and annuloplasty device implantation. Additional procedures included leaflet resection, neochordae insertion, atrial ablation, and papillary muscle shortening. Longer clamp times were associated with number of neochordae (P < 0.01), papillary muscle procedures (P < 0.01), and leaflet resection (P = 0.06). Sequential case number had no impact on cross-clamp time (P = 0.3). Analysis of nonclamp time demonstrated a 71.3% learning percentage (P < 0.01; ie, 28.7% reduction in nonclamp time with each doubling of case number). There were no hospital deaths or incidences of stroke, myocardial infarction, unplanned reoperation, respiratory failure, or renal failure. Median length of stay was 4 days. All patients were discharged home. CONCLUSIONS: Totally endoscopic robotic mitral valve repair can be safely performed after a pretraining regimen with emphasis on experts' current practice and team training. After a pretraining regimen, cross-clamp times were not subject to learning curve phenomena but were dependent on procedural complexity. Nonclamp times were associated with a short learning curve.

Management of blood transfusion in aortic valve surgery: impact of a blood conservation strategy.

BACKGROUND: There are limited data in the literature concerning the effect of a blood conservation strategy (BCS) on aortic valve replacement (AVR) patients. METHODS: From 2007 to 2011, 778 patients underwent AVR at a single institution. During this period, a multidisciplinary BCS was initiated with emphasis on limiting intraoperative hemodilution, tolerance of perioperative anemia, and blood management education for the cardiac surgery care providers. RESULTS: Mortality was 3.0% (23 of 778) overall and 1.7% (9 of 522) for isolated first-time AVR. There was no difference in rates of mortality (p = 0.5) or major complications (p = 0.4) between the pre-BCS and post-BCS groups; however, the BCS was associated with a lower risk of major complications (odds ratio, 1.7; p = 0.046) by multivariable analysis. The incidence of red blood cell (RBC) transfusion decreased from 82.9% (324 of 391) to 68.0% (263 of 387; p < 0.01). Of those patients who did not receive any day-of-operation RBC transfusions, 64.5% (191 of 296) did not receive any postoperative RBC transfusions. Lower risk of RBC transfusion was associated with isolated AVR (p < 0.01), a minimally invasive approach (p < 0.01), and BCS (p < 0.01), whereas a greater risk of RBC transfusion was associated with older age (p < 0.01), prior cardiac operation (p = 0.01), female sex (p < 0.01), and smaller body surface area (p < 0.01). Day-of-operation RBC transfusion of 2 units or more was associated with increased deaths (p = 0.01), prolonged intubation (p < 0.01), postoperative renal failure (p = 0.01), and increased incidence of any complication (p < 0.01). CONCLUSIONS: Perioperative BCS reduced RBC transfusion in AVR patients without an increase in mortality or morbidity. Guidelines for BCS in routine cardiac operations should be extended to AVR patients.

The Impact of a Blood Conservation Program in Complex Aortic Surgery.

OBJECTIVE: Recent Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists (STS/SCA) guidelines highlight the safety of blood conservation strategies in routine cardiac surgery. We evaluated the feasibility and impact of such a program in complex aortic surgery. METHODS: Between March 2010 and October 2011, 63 consecutive aortic replacement procedures were performed: aortic root (n = 17; 27%), ascending aorta (n = 15; 23.8%), aortic arch (n = 19; 30.2%), descending aorta (n = 8; 12.7%), and thoracoabdominal aorta (n = 4; 6.3%). Aortic dissections were present in 32 patients. A multidisciplinary approach to blood conservation included minimal perioperative crystalloid, small priming circuits, hemoconcentration, meticulous hemostasis, and tolerance of postoperative anemia (hemoglobin of ≥ 7mg/dL). RESULTS: Operative mortality was 11.1%. Multivariate predictors of mortality were low preoperative hematocrit (HCT, P = 0.05) and endocarditis (P = 0.021). Seventy-four percent of patients required no intraoperative packed red blood cell (pRBC) transfusion. For nondissection patients, 80.6% required ≤ 1 U of intraoperatively compared to 54.3% in STS benchmark data (P < 0.0001). During the hospital stay, 24 patients (39%) received no pRBCs and 34 patients (54%) received ≤ 1 U of pRBCs. Multivariate predictors of pRBC transfusion were low preoperative HCT (P = 0.04) and cardiopulmonary bypass time (P = 0.01). Discharge hemoglobin/HCT values were 8.7/26.3 compared to preoperative 12.1/35.5 (p < 0.001). Complications were absent in 94% (32/34) of patients receiving ≤1 U compared to 59% (17/29) in patients who received ≥ 2 U (P = 0.001). CONCLUSIONS: These findings demonstrate that a perioperative blood conservation management strategy can be extended to complex aortic surgery and is associated with better clinical outcomes.

Evolution of operative techniques and perfusion strategies for minimally invasive mitral valve repair.

OBJECTIVE: Perfusion strategies and operative techniques for minimally invasive mitral valve repair have evolved over time. During the past decade, our institution's approach has progressed from a port access platform with femoral perfusion to predominantly a central aortic cannulation through a right anterior minithoracotomy incision. We analyzed this institutional experience to evaluate the impact of approach on patient outcomes. METHODS: Between 1995 and 2007, 1282 patients (mean age, 59.3 years; range, 18-99 years) underwent first-time, isolated mitral valve repair using a minimally invasive technique. Patient demographics included peripheral vascular disease (3.2%), chronic obstructive pulmonary disease (8.3%), atherosclerotic aorta (6.5%), cerebrovascular disease (4.3%), and ejection fraction less than 30% (4.3%). Retrograde perfusion was performed in 394 (30.7%) of all patients and endoaortic balloon occlusion in 373 (29.1%); the operative technique was a right anterior minithoracotomy in 1264 (98.6%) and left posterior minithoracotomy in 18 (1.4%). The etiology of mitral disease was degenerative in 73.2%, functional in 20.6%, and rheumatic in 2.4%. Data were collected prospectively using the New York State Cardiac Surgery Report System and a customized minimally invasive surgery data form. Logistic analysis was used to evaluate risk factors and outcomes; operative experience was divided into tertiles. RESULTS: Overall hospital mortality was 2.0% (25/1282). Mortality was 1.1% (10/939) for patients with degenerative etiology and 0.4% (3/693) for patients younger than 70 years of age with degenerative valve disease. Risk factors for death were advanced age (P = .007), functional etiology (P = .010; odds ratio [OR] = 3.3), chronic obstructive pulmonary disease (P = .013; OR = 3.4), peripheral vascular disease (P = .014; OR = 4.2), and atherosclerotic aorta (P = .03; OR = 2.8). Logistic risk factors for neurologic events were advanced age (P = .02), retrograde perfusion (P = .001; OR = 3.8), and emergency procedure (P = .01; OR = 66.6). Interaction modeling revealed that the only significant risk factor for neurologic event was the use of retrograde perfusion in high-risk patients with aortic disease (P = .04; OR = 8.5). Analysis of successive tertiles during this 12-year experience revealed a significant decrease in the use of retrograde arterial perfusion (89.6%, 10.4%, and 0.0%; P < .001) and endoaortic balloon occlusion (89.3%, 10.7%, and 0%; P < .001). The overall frequency of postoperative neurologic events was 2.3% (30/1282) and decreased from 4.7% in the first tertile to 1.2% in the second and third tertiles (P < .001). CONCLUSIONS: Central aortic cannulation through a right anterior minithoracotomy for mitral valve repair allows excellent outcomes in patients with a broad spectrum of comorbidities and has become our preferred approach for most patients undergoing mitral valve repair. Retrograde arterial perfusion is associated with an increased risk of stroke in patients with severe peripheral vascular disease and should be reserved for select patients without significant atherosclerosis.

Reoperative valve surgery in the elderly: predictors of risk and long-term survival.

BACKGROUND: Elderly patients requiring reoperative cardiac surgery for valve disease are considered high risk for immediate outcomes, but little is known about their long-term survival. It is often conjectured that medical therapy provides equivalent late survival in this population, which may dissuade both patient and surgeon from considering reoperation. We analyzed a cohort of such patients undergoing reoperative valve surgery to determine their long-term survival. METHODS: From 1992 through 2007, 363 patients aged 75 years or more underwent reoperative isolated valve surgery; 211 (58%) had aortic valve replacement and 152 (42%) had mitral valve surgery. Mean age was 80.5 years. Hospital outcomes were prospectively recorded. Survival from all-cause death was determined from the Social Security Death Index. RESULTS: Hospital mortality was 13.8% (12.8% for aortic and 15.1% for mitral valve operations; p = 0.52). Multivariable predictors of hospital death were New York Heart Association functional class III or IV heart failure (odds ratio = 3.19, p = 0.012), dialysis (odds ratio = 15.63, p = 0.003), and more than one reoperation (odds ratio = 2.59, p = 0.058). At 5 years, overall survival was 62% ± 3% for all patients (66% ± 4% for aortic and 56% ± 4% for mitral valve patients). For aortic valve patients aged 80 years or more, 5-year survival was 60% ± 0.6%. Life expectancy table analysis predicted a 5-year survival of 57% for an age-matched and sex-matched comparison group. CONCLUSIONS: Reoperative surgery for elderly patients with isolated aortic or mitral valve pathology is associated with excellent long-term survival, particularly when treating aortic valve disease. While in-hospital mortality is higher among the elderly than among younger patients, specific predictors of poor outcome can be identified preoperatively to risk stratify these patients.

Retrograde arterial perfusion, not incision location, significantly increases the risk of stroke in reoperative mitral valve procedures.

BACKGROUND: A recent report suggested that a thoracotomy approach for reoperative mitral valve (MV) procedures was associated with an equivalent mortality and an unacceptable risk of stroke. We assessed these outcomes in a single institution's experience. METHODS: From 1992 through 2007, 905 patients underwent reoperative MV procedures. The approach was a median sternotomy in 612 (67.6%), right anterior thoracotomy in 242 (26.7%), and left posterior thoracotomy in 51 (5.6%). Concomitant procedures in 411 patients (67.6%) included aortic procedures in 189, tricuspid procedures in 170, and coronary artery bypass grafting in 90. Hypothermic fibrillation was used in 65 patients. Logistic analysis was used to analyze risk factors and outcomes. RESULTS: Overall mortality was 12.7% (115 of 905), 6.7% (25 of 371) for first time isolated MV reoperations, and 10.1% (50 of 494) for all isolated MV operations. Overall incidence of stroke was 3.8% (34 of 905); 10.9% (9 of 82) with retrograde arterial perfusion and 3.0% (25 of 824) with central aortic cannulation (p < 0.001). For isolated MV reoperations, the incidence of stroke was 4.3% (21 of 494): 2.9% (7 of 241) for antegrade perfusion and 5.5% (14 of 253) for retrograde perfusion (p = 0.15). Risk factors for death were age (p < 0.001), renal failure (p < 0.01), tricuspid valve disease (p < 0.001), chronic obstructive pulmonary disease (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8 to 4.9; p < 0.001), emergency procedure (OR, 2.9; 95% CI, 1.2 to 6.9; p = 0.02), and ejection fraction less than 0.30 (OR, 1.9; 95% CI, 1.1 to 3.3, p = 0.018). Risk factors for stroke were retrograde perfusion (OR, 4.4; 95% CI, 1.8 to 10.3; p < 0.01) and ejection fraction below 0.30 (OR, 2.1; 95% CI, 0.9 to 5.0; p = 0.09). CONCLUSIONS: The incidence of stroke in reoperative MV operations is associated with perfusion strategies, not with the incisional approach. Reoperative sternotomy and minithoracotomy with central cannulation are both useful for reoperative MV procedures and are associated with low stroke rates.

Ten-year results of folding plasty in mitral valve repair.

BACKGROUND: Folding plasty (FP) for posterior mitral leaflet repair (PLR) is a technique that reduces the height of the repaired leaflet, closes the gap created by leaflet resection by rotation of residual leaflet, and reduces the need for localized annular plication. This report reviews late outcomes with FP repair. METHODS: From January 1994 to August 2006, 1,402 mitral valve repairs were performed for degenerative disease: 1,012 had PLR and 531 had FP technique. RESULTS: Overall hospital mortality was 2.4% (33 of 1,402 patients) and 1.3% (14 of 1,103 patients) for isolated mitral repair. For those patients with PLR, mortality for all procedures was 1.5% (15 of 1,012 patients) and 1.2% (11 of 891 patients) for isolated PLR repairs. Mortality was 0.9% (5 of 531 patients) for FP. In the last 5 years FP was used in 64.4% of PLR, compared with 35.6% of PLR in the prior era (p < 0.001). The 10-year actuarial freedom from mitral reoperation was 89%; 10-year freedom from reoperation or recurrent severe mitral insufficiency was 86% with FP and 87% without (p = 0.76). The 5-year freedom from reoperation or recurrent severe insufficiency was 89% when an annuloplasty device was used and 62% when not used (p < 0.001). CONCLUSIONS: Repair of posterior leaflet prolapse with FP is straightforward and durable. In our experience, FP is currently used for two thirds of PLR. These data also confirm that valve repair for degenerative disease should include an annuloplasty device for optimal late results.

A decade of minimally invasive mitral repair: long-term outcomes.

BACKGROUND: Short-term results with minimally invasive approaches for mitral valve repair in degenerative disease have been encouraging, with potential for diminishing blood loss and hospital length of stay. Little is known, however, about the long-term efficacy of this approach. This report analyzes a single institution's results over 12 years with minimally invasive mitral repair. METHODS: Since 1986, 3,057 patients have undergone mitral valve repair; 1,601 patients had degenerative disease and are the subject of this report. Minimally invasive mitral repair was done in 1071 patients with a right anterior minithoracotomy and direct vision. Clinical and echocardiographic variables were entered prospectively into a database. RESULTS: Hospital mortality was 2.2% for all patients (36 of 1601); 1.3% for isolated minimally invasive (9 of 712) and 1.3% (3 of 223) for isolated sternotomy mitral valve repair; and 3.6% (24 of 666) for valve repair plus a concomitant cardiac procedure. For isolated valve repair, 8-year freedom from reoperation was 91% +/- 2% for sternotomy and 95% +/- 1% for minimally invasive (p = 0.24), and 8-year freedom from reoperation or severe recurrent insufficiency was 90% +/- 2% for sternotomy and 93% +/- 1% for minimally invasive (p = 0.30). Eight-year freedom from all valve-related complications was 86% +/- 3% for sternotomy and 90% +/- 2% for minimally invasive (p = 0.14). CONCLUSIONS: These data indicate that long-term outcomes after minimally invasive mitral repair are excellent and equivalent to results achieved with sternotomy. In view of previously published advantages of short-term morbidity, minimally invasive approaches to mitral valve surgery deserve expanded use.

Minimally invasive reoperative isolated valve surgery: early and mid-term results.

OBJECTIVE: Minimally invasive, nonsternotomy approaches for valve procedures may reduce the risks associated with cardiac surgery after prior sternotomy and may improve outcomes. We analyzed our institutional experience to test this hypothesis. METHODS: Between 1995 and 2002, 498 patients with previous cardiac operations via sternotomy underwent isolated valve surgery: 337 via median sternotomy (aortic = 160; mitral = 177) and 161 via mini-thoracotomy (aortic = 61; mitral = 100). Data were collected prospectively using the New York State Cardiac Surgery Report Form. RESULTS: Preoperative incidences of congestive heart failure, renal disease, and nonelective procedures were higher in the sternotomy group. Hospital mortality was significantly lower with the minimally invasive approach, 5.6% (9/161) versus 11.3% (38/337) (univariate, p = 0.04). However, multivariate analysis (odds ratio: 95% confidence intervals, p value) revealed that chronic obstructive pulmonary disease (6.6: 1.4 to 3.1, p = 0.001), renal disease (4.1: 1.52 to 11.2, p = 0.01), cerebrovascular disease (2.2: 1.03 to 4.78, p = 0.04), and ejection faction <30% (1.5: 0.96 to 5.5, p = 0.06) were associated with increased mortality. While mean bypass time, cross-clamp times, and stroke rates were comparable between groups, patients undergoing minimally invasive valve surgery had no deep wound infections (0% vs 2.4%, p = 0.05), less need for blood products (p = 0.02), and shorter hospital stays (p = 0.009). Five-year survival was higher with minimally invasive techniques as compared to a sternotomy approach (92.4 +/- 2% and 86.0 +/- 2%, respectively, p = 0.08). CONCLUSIONS: Reoperative valve surgery can be safely performed using a nonsternotomy, minimally invasive approach, with at least equal mortality, less hospital morbidity, decreased hospital length of stay, and slightly favorable mid-term survival as compared to sternotomy.

Minimally invasive aortic valve surgery in the elderly: a case-control study.

INTRODUCTION: Although minimally invasive aortic valve surgery (MIAVR) is performed in many centers, few studies have compared its results to a standard sternotomy (SS) approach. We assessed the hypothesis that, when compared with SS in the elderly population, MIAVR has similar morbidity and mortality and allows faster hospital recovery. METHODS AND RESULTS: From January 1995 through February 2002, 515 patients over age 65 underwent isolated aortic valve replacement. Using data gathered prospectively, 189 MIAVR patients were matched with 189 SS patients by age, ventricular function, valvular pathology, urgency of operation, diabetes, previous cardiac surgery, renal disease, and history of stroke. In each group, 56.1% of patients underwent non-elective procedures, and 28% were >or=80 years old. Hospital mortality (6.9%) and freedom from postoperative morbidity (82.5% versus 81.5%, P=0.79) were similar. Multivariate analysis revealed that urgent procedures [Odds Ratio (OR)=3.97; P=0.03], congestive heart failure (OR=3.94; P=0.03), and ejection fraction <30% (OR=4.16; P=0.03) were significant predictors of hospital mortality. Prolonged length of stay was associated with age (P=0.05), preoperative stroke (OR=3.5,P=0.001), CHF (OR=2.2, P=0.004), and sternotomy approach (OR=2.3,P=0.002) by multivariate analysis. More MIAVR patients were discharged home (52.6% versus 38.6%,P=0.03) rather than to rehabilitation facilities. Three year actuarial survival revealed no difference between groups. CONCLUSIONS: Minimally invasive aortic valve surgery is safe in elderly patients, with morbidity and mortality comparable to sternotomy approach. The shorter hospital stay and greater percentage of patients discharged home after MIAVR reflect enhanced recovery with this technique.