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OBJECTIVES: To compare outcomes after the development of early (≤30 days) versus delayed (>30 days) deep sternal wound infection (DSWI) after cardiac surgery. METHODS: Between 2005 and 2016, 64 patients were treated surgically for DSWI following cardiac surgery. Thirty-three developed early DSWI, while 31 developed late DSWI. The mean follow-up was 34.1 ± 32.3 months. RESULTS: Survival for the entire cohort at 1, 3, and 5 years was 93.9%, 85.1%, and 80.8%, respectively. DSWI diagnosed early and attempted medical management was strongly associated with overall mortality (hazard ratio [HR], 25.0 and 9.9; 95% confidence intervals [CIs], 1.18-52.8 and 1.28-76.5; p-value .04 and .04, respectively). Survival was 88.1%, 77.0%, 70.6% and 100%, 94.0% and 94.0% at 1, 3, and 5 years in the early and late DSWI groups, respectively (log-rank = 0.074). Those diagnosed early were more likely to have a positive wound culture (odds ratio [OR], 0.06; 95% CI, 0.01-0.69; p = .024) and diagnosed late were more likely to be female (OR, 8.75; 95% CI, 2.0-38.4; p = .004) and require an urgent DSWI procedure (OR, 9.25; 95% CI, 1.86-45.9; p = .007). Both early diagnosis of DSWI and initial attempted medial management were strongly associated with mortality (HR, 7.48; 95% CI, 1.38-40.4; p = .019 and HR, 7.76; 95% CI, 1.67-35.9; p = .009, respectively). CONCLUSIONS: Early aggressive surgical therapy for DSWI after cardiac surgery results in excellent outcomes. Those diagnosed with DSWI early and who have failed initial medical management have increased mortality.
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Procedimentos Cirúrgicos Cardíacos , Infecção da Ferida Cirúrgica , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Estudos de Coortes , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Esterno/cirurgiaRESUMO
BACKGROUND: Debate continues in regard to the optimal surgical approach to the mitral valve for degenerative disease. METHODS: Between February 2004 and July 2015, 363 patients underwent mitral valve repair for degenerative mitral valve disease via either sternotomy (sternotomy, n = 109) or small right anterior thoracotomy (minimally invasive, n = 259). Survival, need for mitral valve reoperation, and progression of mitral regurgitation more than two grades were compared between cohorts using time-based statistical methods and inverse probability weighting. RESULTS: Survival at 1, 5, and 10 years were 99.2, 98.3, and 96.8 for the sternotomy group and 98.1, 94.9, and 94.9 for the minimally invasive group (hazard ratio: 0.39, 95% confidence interval [CI] 0.11-1.30, p = .14). The cumulative incidence of need for mitral valve reoperation with death as a competing outcome at 1, 3, and 5 years were 2.7%, 2.7%, and 2.7% in the sternotomy cohort and 1.5%, 3.3%, and 4.1% for the minimally invasive group (subhazard ratio (SHR) 1.17, 95% CI: 0.33-4.20, p = .81). Cumulative incidence of progression of mitral regurgitation more than two grades with death as a competing outcome at 1, 3, and 5 years were 5.5%, 14.4%, and 44.5% for the sternotomy cohort and 4.2%, 9.7%, and 20.5% for the minimally invasive cohort (SHR: 0.67, 95% CI: 0.28-1.63, p = .38). Inverse probability weighted time-based analyses based on preoperative cohort assignment also demonstrated equivalent outcomes between surgical approaches. CONCLUSIONS: Minimally invasive and sternotomy mitral valve repair in patients with degenerative mitral valve disease is associated with equivalent survival and repair durability.
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Insuficiência da Valva Mitral , Esternotomia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Toracotomia , Resultado do TratamentoRESUMO
BACKGROUND: Consensus guidelines recommend surgical aortic valve replacement (SAVR) over transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis aged < 65 years. This analysis evaluates clinical practice and outcomes of TAVR and SAVR in patients < 60 years. METHODS: We identified 2,360 patients aged < 60 years including 523 TAVR (22.2%) and 1,837 SAVR (77.8%) procedures from 2013-2021 using the California Department of Health Care Access and Information database. The median follow-up time was 2.4 (IQR:1.1-4.5) years after TAVR and 4.9 (IQR:2.8-6.9) years after SAVR. The primary outcome was 5-year survival. Secondary outcomes included cumulative incidences of reoperation, endocarditis, stroke, and heart failure readmissions with death as a competing risk, compared using propensity score matching. RESULTS: Between 2013 and 2021 TAVR rates in patients aged < 60 years increased from 7.2% to 45.7% (annual increase of 4.7%, p<0.001). Thirty-day mortality was similar for SAVR and TAVR (0.2% vs. 0.4% (p=0.20). In 358 propensity-matched pairs, TAVR was associated with an increased hazard of 5-year mortality (HR 2.5, 95% CI 1.1-3.7, p=0.02). There was no significant difference in the cumulative incidences of reoperation (2.2% vs. 3.8%, p=0.25), stroke (1.1% vs. 0.8%, p=0.39), endocarditis (0.8% vs. 0.4%, p=0.38), and heart failure readmission (1.9% vs. 1.2%, p=0.10). CONCLUSIONS: TAVR use approaches SAVR use in patients aged < 60 years in California and is associated with significantly worse 5-year survival. This may indicate a need for randomized trials to inform best practice recommendations.
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OBJECTIVE: To compare outcomes with wrapped (pulmonary autograft inclusion) versus unwrapped techniques in adults with bicuspid aortic valves undergoing the Ross procedure. METHODS: Between 1992 and 2019, 129 adults with bicuspid aortic valves (aged ≥18 years) underwent the Ross procedure by a single surgeon. Patients were divided into those without autograft inclusion (unwrapped, n = 71) and those with autograft inclusion (wrapped, n = 58). Median follow-up was 10.3 years (interquartile range, 3.0-16.8 years). Need for autograft reintervention was analyzed using competing risks. RESULTS: Pre- and intraoperative characteristics as well as 30-day morbidity or mortality did not differ between cohorts. Survival at 1, 5, and 10 years, respectively, was 97.2%, 97.2%, and 95.6% in the unwrapped cohort and 100%, 100%, and 100% in the wrapped cohort (P = .15). Autograft valve failure occurred in 25 (35.2%) of the unwrapped and 3 (5.2%) of the wrapped patients. Competing risks analysis demonstrated the wrapped cohort to have a lower need for autograft reintervention (subhazard ratio, 0.28, 95% confidence interval, 0.08-0.91; P = .035). The cumulative incidence of autograft reintervention (death as a competing outcome) at 1, 5, and 10 years, respectively, was 10.2%, 14.9%, and 26.8% in the unwrapped cohort and 4.0%, 4.0%, and 4.0% in the wrapped cohort. CONCLUSIONS: In adults with bicuspid aortic valves, the Ross procedure with pulmonary autograft inclusion stabilizes the aortic root preventing dilatation and reduces the need for reoperation. The autograft inclusion technique allows the Ross procedure to be performed in this population with excellent long-term outcomes.
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Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Doença da Válvula Aórtica Bicúspide , Valva Pulmonar , Adulto , Humanos , Adolescente , Doença da Válvula Aórtica Bicúspide/cirurgia , Valva Aórtica/cirurgia , Valva Pulmonar/transplante , Autoenxertos , Transplante Autólogo/efeitos adversos , Reoperação/efeitos adversos , Resultado do Tratamento , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: The objective of this study was to identify trainee knowledge gaps in reimbursement and compensation, determine the perceived importance of understanding these topics, and to explore if the Thoracic Surgery Curriculum needs additional educational material. METHODS: The Thoracic Surgical Residents Association Executive Committee selected the research proposal and distributed an anonymous electronic survey to 531 Accreditation Council for Graduate Medical Education cardiothoracic surgery trainees. Standard descriptive statistics and regression analyses were performed. RESULTS: One hundred fourteen responses were collected (response rate, 21.5%). Most trainees understood little to none about how attending surgeons are reimbursed (n = 74, 69%). Most trainees reported knowing little or nothing about pay-for-performance compensation (n = 73, 67%), bundled care (n = 82, 75%), or value-based reimbursement (n = 84, 77%). Approximately 20% of trainees were accurate in estimating surgeon reimbursement for 3 common cardiothoracic surgery procedures to within 20% of the true reimbursement value, whereas approximately 30% were accurate to within 50% of the true reimbursement value. No respondent characteristics were found to be associated with a more or less accurate reimbursement response. Additionally 81% of trainees (n = 87) responded that by the conclusion of training, understanding surgeon reimbursement is very important or extremely important and 90% of trainees (n = 95) either somewhat agreed or strongly agreed with including these topics in the Thoracic Surgical Curriculum. CONCLUSIONS: Despite acknowledging the importance of understanding physician compensation and reimbursement, cardiothoracic surgery trainees do not understand how the current models work. This study exemplifies the need for a succinct curriculum in this domain for trainees nationwide.
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Internato e Residência , Cirurgiões , Cirurgia Torácica , Competência Clínica , Currículo , Educação de Pós-Graduação em Medicina , Humanos , Reembolso de Incentivo , Cirurgiões/educação , Inquéritos e Questionários , Cirurgia Torácica/educaçãoRESUMO
Repair of concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain requires a technically complex operation colloquially termed the commando procedure. Surgical outcomes of this procedure are not well described. The objective of this study was to examine outcomes of the commando procedure at our center. We identified all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of 363 patients, 41 underwent reconstruction of the aortomitral curtain. Survival analysis and multivariable modeling were used to examine outcomes and risk factors for mortality. The median age was 52 (IQR 44-71) years. Preoperatively, 4 of 41 (9.8%) patients had renal failure, and 10 of 41 (24.4%) had a stroke. The most common surgical indication was endocarditis in 25 of 41 (61.0%) patients. 25 of 41 (61.0%) patients underwent redo sternotomy, and 23 of 41 (56.1%) had previous prosthetic valves. Operative mortality was 14 of 41 (34.1%), and 8 of 41 (9.5%) patients received a permanent pacemaker. Survival at 1, 3, and 5 years was 55.4% (95% confidence interval (CI), 40.6-75.5%), 50.3% (35.0-72.3%), and 37.7% (19.3-73.9%) respectively. Cox proportional hazards regression identified previous sternotomy (HR 4.76, 95% CI 1.21-18.73), and female gender (HR 1.39, 95% CI 1.17-13.82) as risk factors for mortality. Patients undergoing reconstruction of the aortomitral curtain represent a high-risk population with complex surgical indications. Due to high perioperative morbidity and mortality, this procedure should be performed only when necessary. Despite a high up front morbidity burden, outcomes remain favorable for patients who survive the initial hospitalization.
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OBJECTIVE: We report a single-center experience using the hybrid procedure, consisting of open debranching, followed by endovascular aortic repair, for treatment of arch/proximal descending thoracic/thoracoabdominal aortic aneurysms (TAAA). METHODS: From 2005 to 2010, 51 patients (33 men; mean age, 70 years) underwent a hybrid procedure for arch/proximal descending thoracic/TAAA. The 30-day and in-hospital morbidity and mortality rates, and late endoleak, graft patency, and survival were analyzed. Graft patency was assessed by computed tomography, angiography, or duplex ultrasound imaging. RESULTS: Hybrid procedures were used to treat 27 thoracic (16 arch, 11 proximal descending thoracic) and 24 TAAA (Crawford/Safi types I to III: 3; type IV: 12; type V: 9). The hybrid procedure involved debranching 47 arch vessels or 77 visceral/renal vessels using bypass grafts, followed by endovascular repair. Seventy-five percent of debranching and endovascular repair procedures were staged, with an average interval of 28 days. Major 30-day and in-hospital complications occurred in 39% of patients and included bypass graft occlusion in four, endoleak reintervention in two, and paraplegia in one. Mortality was 3.9%. During a mean follow-up of 13 months, three additional type II endoleaks required intervention, and one bypass graft occluded. No aneurysm rupture occurred during follow-up. Primary bypass graft patency was 95.3%. Actuarial survival was 86% at 1 year and 67% at 3 years. CONCLUSION: The hybrid procedure is associated with acceptable rates of mortality and paraplegia when used for treatment of arch/proximal descending thoracic/TAAA. These results support this procedure as a reasonable approach to a difficult surgical problem; however, longer follow-up is required to appraise its ultimate clinical utility.
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Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/cirurgia , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Los Angeles , Masculino , Pessoa de Meia-Idade , Paraplegia/etiologia , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Grau de Desobstrução VascularRESUMO
BACKGROUND: To report a single-center experience of aortic stent-grafting for the treatment of acute, complicated, type B aortic dissections. METHODS: A retrospective review was conducted of the data obtained from all patients who underwent endovascular stent-grafting for acute, type B aortic dissection between 2006 and 2009. The primary and secondary endpoints were 30-day mortality and morbidity rates, respectively. RESULTS: In all, 104 thoracic endovascular aortic aneurysm repairs were performed during the study period. Nine (8.6%) patients (six men; mean age: 65 years) underwent thoracic endovascular aortic aneurysm repair for acute, complicated, type B aortic dissections. Seven (78%) patients had uncontrolled hypertension on presentation. Visceral branch vessel involvement of the dissection was limited to the celiac axis origin in one patient with no evidence of visceral malperfusion. The indication for repair was aortic rupture in five patients, renal malperfusion in two, and persistent pain in the remaining two. Average time taken from presentation to surgery was 5.5 days. Two patients presenting with aortic ruptures had retrograde extension of the dissection that required replacement of the aortic valve and ascending aorta. The mean length of thoracic aorta covered was 21 cm. Complete coverage of the left subclavian artery was required in three patients and partial coverage in two. On completion angiogram, two type I endoleaks were detected, one of which was resolved by postoperative day 5. The 30-day mortality rate was 22%. One mortality was secondary to aortic rupture. The other mortality was due to multiorgan system failure. Seven patients (78%) had one or more major complications. There were no strokes or paraplegia. CONCLUSION: The association of morbidity and mortality with endovascular stent-grafting for acute, complicated, type B aortic dissections is significant, which most likely reflects the lethal nature of the disease. The precise role of endovascular treatment in these patients remains to be defined.
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Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/mortalidade , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aortografia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Los Angeles , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Estudos Retrospectivos , Stents , Fatores de Tempo , Resultado do TratamentoRESUMO
A retrospective cohort study was conducted in which 129 adult patients with bicuspid aortic valves underwent the Ross procedure with either a standard root inclusion technique or a modified technique whereby the pulmonary autograft is wrapped in a vascular conduit. Primary outcomes were survival and the need for pulmonary autograft reintervention. Competing risk analysis demonstrated the wrapped technique reduced pulmonary autograft reintervention.
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BACKGROUND: Many online resources currently provide healthcare information to the public. In 2015, the Society of Thoracic Surgeons (STS) created a multimedia web portal (ctsurgerypatients.org) to educate the public regarding cardiothoracic surgery and provide an informative tool to which cardiothoracic surgeons could refer patients. METHODS: A patient education task force was created, and disease-specific content was created for 25 pathological conditions. After launching the website online, a marketing campaign was initiated to make STS members aware of its availability. Website visits were monitored, and an online survey for public users was created. An email survey was sent to STS members to evaluate awareness and content. Surveys were analyzed for effectiveness and utilization by both public users and STS member surgeons. RESULTS: From 2016 to 2018, the website had more than 1 million visits, with visits increasing yearly. Surveyed user ratings of the website were positive regarding quality and utility of the information provided. STS member response was poor (379 responses of 6347 emails), and 78.3% of responders were unaware of the website. Surgeon responders were positive about the content, though many still refrain from referring patients. CONCLUSIONS: Online education for cardiothoracic surgery is seeing increased public use, with high ratings for content and utility. Despite aggressive marketing to STS members, most remain unaware of this website's existence. Those who are aware approve of its content, but adoption of referring patients to it has been slow. Improved strategies are necessary to make surgeons aware of this STS-provided service and increase patient referrals to it.
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Educação a Distância/estatística & dados numéricos , Internet , Educação de Pacientes como Assunto/estatística & dados numéricos , Cirurgia Torácica/educação , Utilização de Instalações e Serviços , Humanos , Aceitação pelo Paciente de Cuidados de Saúde , Sociedades Médicas , Cirurgiões , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. METHODS: Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. RESULTS: Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01). CONCLUSIONS: A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.
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Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Doença Aguda , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/mortalidade , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/mortalidade , California/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
The aortic root is the junction between the heart and aorta, containing the aortic valve and the coronary artery ostia. Various pathologic conditions arise in this region requiring complex surgical correction. These include aneurysmal dilatation with and without aortic regurgitation, acute aortic dissection extending below the sinotubular junction, and infective endocarditis with valve and periannular destruction. Multiple strategies for correction of these complex surgical issues exist, with excellent early results and long-term survival.
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Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Dissecção Aórtica/etiologia , Aorta , Aneurisma Aórtico/etiologia , HumanosRESUMO
Type A aortic dissection is a surgical emergency occurring when an intimal tear in the aorta creates a false lumen in the ascending aorta. Prompt diagnosis and surgical treatment are imperative to optimize outcomes. Surgical repair requires replacement of the ascending aorta with or without aortic root or aortic arch replacement. Surgical outcomes for this highly lethal diagnosis have improved, with contemporary survival to discharge at Centers of Excellence of 85% to 90%. Survival is related to prompt treatment, preexisting medical comorbidities, presence or absence of end organ malperfusion, extent of aortic repair required, and the development of postoperative complications.
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Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Doença Aguda , Dissecção Aórtica/etiologia , Dissecção Aórtica/mortalidade , Aorta , Aneurisma da Aorta Torácica/etiologia , Aneurisma da Aorta Torácica/mortalidade , HumanosRESUMO
OBJECTIVE: To evaluate outcomes after mitral valve repair. METHODS: Between May 1999 and June 2015, 446 patients underwent mitral valve repair. Isolated mitral valve annuloplasty was excluded. A total of 398 (89%) had degenerative valve disease. Mean follow-up was 5.5 ± 3.8 years. Postoperative echocardiograms were obtained in 334 patients (75%) at a mean of 24.3 ± 13.7 months. RESULTS: Survival was 97%, 96%, 95%, and 94% at 1, 3, 5, and 10 years. Risk factor analysis showed age >60 years and nondegenerative etiology predict death (hazard ratio, 2.91; 95% confidence interval, 1.06-8.02, P = .038; and hazard ratio, 1.87; 95% confidence interval, 1.16-3.02, P = .010, respectively). Considering competing risks due to mortality, the cumulative incidence of reoperation was 2.8%, 4.2%, 5.1%, and 9.6% at 1, 3, 5, and 10 years. Competing risk proportional hazard survival regression identified nondegenerative etiology and previous cardiac surgery as predictors of reoperation, and posterior repair was protective (all P < .05). Cumulative incidence of progression of mitral regurgitation (2 or more grades) with mortality as a competing risk was 4.7%, 10.5%, 21.0%, and 35.8% at 1, 3, 5, and 10 years. Patients with previous sternotomy, repair or coronary artery bypass grafting, and concurrent tricuspid valve procedure or isolated anterior leaflet repair were more likely to develop progression of mitral regurgitation (all P < .05), and posterior leaflet repair was protective (P = .038). On multivariate analysis diabetes, previous coronary artery bypass grafting and concurrent tricuspid valve intervention predicted MR progression. CONCLUSIONS: Mitral valve repair has excellent outcomes. Our results demonstrate failures appear to occur less in those who undergo posterior leaflet repair.
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Progressão da Doença , Insuficiência da Valva Mitral/epidemiologia , Valva Mitral/cirurgia , Fatores Etários , California/epidemiologia , Estudos de Coortes , Ponte de Artéria Coronária , Diabetes Mellitus/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/cirurgia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Valva Tricúspide/cirurgiaRESUMO
BACKGROUND: The risk of patient-prosthesis mismatch drives most surgeons to select the largest bioprosthesis possible during aortic valve replacement, but interactions between the native aortic annulus and valve prosthesis remain poorly defined. We examined the hemodynamic and functional consequences of oversizing contemporary bioprostheses in an in vitro model. METHODS: Three sizes each (21, 23, and 25 mm) of 5 aortic bioprostheses (Magna, Edwards Lifesciences, Irvine, CA; Trifecta and Epic, St. Jude, St. Paul, MN; and Mosaic and Hancock II, Medtronic, Minneapolis, MN) were tested on a mock annulus in a pulsatile aortic simulator. After the annulus was sized to match each valve, the annulus was decreased by 3 mm and then by 6 mm to simulate oversizing. We measured the effective orifice area and the mean pressure gradient. Changes in prosthetic leaflet behavior and geometric orifice area were assessed with slow-motion video. Statistical analysis used mixed-effects models for repeated-measures data, allowing comparison within and between groups. RESULTS: For each valve model and size, oversizing resulted in decreased effective orifice areas and geometric orifice areas and increased pressure gradients. This was more pronounced with smaller valve sizes and higher flow rates but varied between valve types. Slow-motion imaging revealed this change in geometric orifice area was a result of an inward shift of the valve leaflet hinge point. CONCLUSIONS: Bioprosthetic oversizing impairs hemodynamic performance of aortic valve bioprostheses. The magnitude of this effect varies by valve model and size. Clinically, these data suggest that during aortic valve replacement, placing a valve whose internal orifice closely matches the aortic annulus will provide the optimal hemodynamic performance.
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Valva Aórtica/fisiologia , Bioprótese , Próteses Valvulares Cardíacas , Hemodinâmica , Modelos Cardiovasculares , Valva Aórtica/anatomia & histologia , Valva Aórtica/cirurgia , Humanos , Desenho de PróteseRESUMO
OBJECTIVES: Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy. METHODS: Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed. RESULTS: Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups. CONCLUSION: Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.