Valve-Sparing Root Replacement Provides Excellent Midterm Outcomes for Bicuspid Valve Aortopathy.

BACKGROUND: Standard therapy for aortic root dilation in the setting of bicuspid aortic valves remains use of a composite valve conduit. The long-term durability of valve-sparing root replacement (VSRR) in bicuspid aortopathy is presently unclear. In this study, the midterm results of performing VSRR in the setting of a bicuspid valve was analyzed. METHODS: A single institutional database identified 280 patients who underwent VSRR from 2005 to 2016. Outcomes were analyzed in 60 consecutive patients undergoing a VSRR in the setting of a bicuspid aortic valve with aortic insufficiency (AI). Patients were followed prospectively and had annual echocardiograms. RESULTS: The average age in this series was 42 ± 11 years. Eighty percent were men and 33% had New York Heart Association class III to IV symptoms. More than 2+ AI was present in 42% of patients preoperatively. The incidence of operative death, stroke, and renal failure was 0%. Mean follow-up was 39 ± 30 months. At latest follow-up, 62% of patients had zero AI and 87% of patients had <1+ AI. At 5 years, freedom from >2+ AI was 97% and freedom from AVR was 96%. Preoperative AI was not found to be a significant risk factor for postoperative >2+ AI (p = 0.61) or AVR (p = 0.61). CONCLUSIONS: VSRR can be safely and effectively performed in young patients with bicuspid valve anatomy regardless of degree of preoperative AI. Valve function is durable and the incidence of valve-related complications is low. VSRR is an attractive and potentially superior option to conventional root replacement in appropriately selected patients with bicuspid aortopathy.

Valve Sparing Root Replacement Provides Similar Midterm Outcomes in Bicuspid and Trileaflet Valves.

BACKGROUND: Valve-sparing aortic root replacement (VSRR) is an established treatment for aortic root pathology for trileaflet valves. The safety and durability of VSRR in bicuspid aortopathy is unclear. In this study, outcomes of performing VSRR in the setting of bicuspid and trileaflet valves were compared. METHODS: An institutional database identified 294 patients who underwent VSRR from 2005 to 2017. Of these, 225 had trileaflet valves and 69 had bicuspid valves. Patients were followed prospectively and had annual postoperative echocardiograms. Propensity-matched comparisons were made between trileaflet and bicuspid valve patients. RESULTS: The average patient age for trileaflet valves was 46.0 ± 13.5 versus 42.7 ± 12.2 years for bicuspid patients (p = 0.07). There was a higher presence of preoperative >2+ aortic insufficiency (AI) present in bicuspid patients (63.8%) compared with trileaflet patients (31.1%) (p < 0.01). Mean follow-up was 39 months and was 98% complete. At 5 years, the cumulative incidence of >2+ AI and aortic valve replacement (AVR) was 2.0% and 4.3% in trileaflet patients and 7.7% (p = 0.75) and 7.7% (p = 0.81) in bicuspid patients. Preoperative >2+ AI was not predictive of >2+ postoperative AI (p = 0.62) nor AVR (p = 0.49). Five-year survival was no different between groups (trileaflet: 98%, bicuspid: 84%, p = 0.24). CONCLUSIONS: VSRR can be safely and effectively performed in patients with trileaflet and bicuspid valves. Operative outcomes and valve function were equivalent in bicuspid and trileaflet patients in midterm follow-up. Performance of VSRR is a viable term option in the setting bicuspid aortic valve aortopathy.

Hybrid coronary revascularization for the treatment of multivessel coronary artery disease.

Coronary artery disease (CAD) has typically been treated either medically, with percutaneous coronary intervention (PCI), or with coronary artery bypass grafting (CABG). As advances in stent technology and minimally invasive surgery have developed, a third option has emerged: hybrid coronary revascularization (HCR). In HCR, minimally invasive CABG and PCI are both employed to treat a single patient, often during the same hospital stay. Patients appropriate for this technique vary widely, from low-risk patients with low SYNTAX lesions outside the left anterior descending artery (LAD), to high-risk patients with multiple comorbidities who are felt by the heart team to benefit most by avoiding a sternotomy. Across both our experience and other series in the literature, mortality with HCR is around 1%. Hospital length of stay is less than one week, and typically less than after conventional CABG, but longer than with isolated PCI. Return to baseline activity is substantially shorter after minimally invasive CABG compared to conventional CABG due to the avoidance of a sternotomy; deep sternal wound infections are entirely avoided. Mid-term need for repeat revascularization may be higher with HCR, though randomized data are lacking. In conclusion, HCR is an evolving method to treat multivessel CAD with favorable early results in high volume centers, though growth in the field is limited by surgical experience and success with minimally invasive techniques.

Bicuspid aortic valve repair in the setting of severe aortic insufficiency.

BACKGROUND: Bicuspid aortic valve (BAV) is a common cardiac anomaly that affects 0.5-2% of adults. Valve sparing root replacement (VSRR) in bicuspid aortopathy is gaining popularity. We discuss the technical aspects of the procedure as well as the mid- to long-term results of performing VSRR in the setting of a bicuspid valve. METHODS: A single institutional database identified 280 patients who underwent VSRR from 2005-2016. Outcomes were analyzed in 60 consecutive patients undergoing a VSRR in the setting of a BAV with aortic regurgitation (AR). Patients were followed prospectively and had annual echocardiograms. RESULTS: The average age in this series was 42±11 years. Moderate or more AR was present in 50% of patients preoperatively. The incidence of operative death, stroke, and renal failure was 0%. Mean follow-up was 39±30 months. At latest follow-up, 62% of patients had zero AR and 87% of patients had <1+ AR. At 9 years, freedom from >2+ AR was 97% and freedom from aortic valve repair (AVR) was 96%. CONCLUSIONS: VSRR can be safely and effectively performed in young patients with bicuspid valve anatomy regardless of degree of pre-operative AR. Valve function is durable and the incidence of valve-related complications is low. VSRR is an attractive and potentially superior option to conventional root replacement in appropriately selected patients with bicuspid aortopathy.

Reviewing hybrid coronary revascularization: challenges, controversies and opportunities.

Two main approaches to myocardial revascularization currently exist, coronary artery bypass and percutaneous coronary intervention. In patients with advanced coronary artery disease, coronary artery bypass surgery is associated with improved long term outcomes while percutaneous coronary intervention is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach. This new approach, hybrid coronary revascularization, has shown encouraging early results. Minimally invasive techniques for bypass surgery have played a large part of bringing this approach into contemporary practice.

Optimal temperature management in aortic arch operations.

Hypothermic circulatory arrest is a critical component of aortic arch procedures, without which these operations could not be safely performed. Despite the use of hypothermia as a protective adjunct for organ preservation, aortic arch surgery remains complex and is associated with numerous complications despite years of surgical advancement. Deep hypothermic circulatory arrest affords the surgeon a safe period of time to perform the arch reconstruction, but this interruption of perfusion comes at a high clinical cost: stroke, paraplegia, and organ dysfunction are all potential-associated complications. Retrograde cerebral perfusion was subsequently developed as a technique to improve upon the rates of neurologic dysfunction, but was done with only modest success. Selective antegrade cerebral perfusion, on the other hand, has consistently been shown to be an effective form of cerebral protection over deep hypothermia alone, even during extended periods of circulatory arrest. A primary disadvantage of using deep hypothermic circulatory arrest is the prolonged bypass times required for cooling and rewarming which adds significantly to the morbidity associated with these procedures, especially coagulopathic bleeding and organ dysfunction. In an effort to mitigate this problem, the degree of hypothermia at the time of the initial circulatory arrest has more recently been reduced in multiple centers across the globe. This technique of moderate hypothermic circulatory arrest in combination with adjunctive brain perfusion techniques has been shown to be safe when performing aortic arch operations. In this review, we will discuss the evolution of these protection strategies as well as their relative strengths and weaknesses.

Transcatheter Aortic Valve Replacement: Current Technology and Future Directions.

Transcatheter aortic valve replacement as an alternative to open surgical repair is rapidly becoming more used in high-risk patients with aortic stenosis. Transcatheter aortic valve replacement offers the benefit of being much less invasive than traditional surgical repair and has evolved as a therapeutic option for patients with prohibitive surgical risk or those deemed surgically inoperable. Nevertheless, despite its potential to mitigate risk in this frail population, it comes with its own unique set of complications. Technological advancements in valve structure, function, and delivery have and continue to attempt to minimize these risks. This review aims to summarize current advancements in transcatheter aortic valve replacement technology while also introducing areas of future direction in this exciting new field.

Outcomes for Transcatheter Aortic Valve Replacement in Nonagenarians.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) may offer extreme-aged patients a treatment alternative to surgical aortic valve replacement (SAVR). The objective of this study was to describe outcomes of TAVR in nonagenarians using transfemoral and alternative access techniques. METHODS: In a retrospective review, we found 95 nonagenarians who underwent TAVR from September 2007 through February 2014 at Emory University using a balloon expandable valve: transfemoral (n = 66), transapical (n = 14), transaortic (n = 14), and transcarotid (n = 1). Morbidity and 30-day and midterm mortality were assessed. Kaplan-Meier plots were used to determine midterm survival rates. RESULTS: The mean age of the patients was 91.8 ± 1.8 years, and 49 (52%) were female. Postoperative morbidity included 1 patient (1%) each with stroke, myocardial infarction, pneumonia, and renal failure. The mean postoperative length of stay was 6.8 ± 5.1 days for all patients. Overall 30-day mortality was 3.2%, much less than The Society of Thoracic Surgeons predicted risk of mortality of 14.5% ± 7.3%. There were no deaths in the transfemoral patients, but there were 2 transapical deaths (14.3%) and 1 transaortic death (7.1%). The Kaplan-Meier estimate of median survival was 2.6 years. CONCLUSIONS: Extreme-aged nonagenarian patients may have excellent outcomes from TAVR at 30-day and midterm follow-up. Alternative access TAVR is associated with higher morbidity and mortality than transfemoral TAVR. Referral for TAVR of nonagenarians should not be precluded based on age alone.

Conservative management of intraoperative tracheal injury during cardiac operations.

Iatrogenic intraoperative tracheal injuries are rare in cardiac operations. Management of this complication is not well described because of the low incidence and lack of reported cases. We present an 82-year-old woman who sustained a tracheal injury during aortic valve replacement. Soft tissue coverage of the trachea was obtained, the original cardiac operation was completed, and she was otherwise managed conservatively. She recovered without further complication and was discharged home 1 week after the surgical procedure.

Primary pericardial mesothelioma in a 19-year-old presenting as pericarditis.

Primary pericardial mesothelioma is a rare clinical entity. The association between asbestos and pericardial mesothelioma has not been well established, partly due to the small number of reported patients. Treatment options are limited for this very aggressive cancer. Surgical resection in the form of pericardiectomy can be curative, but owing to the frequently late presentation, surgical intervention is usually palliative. Chemotherapy and radiotherapy have overall poor results. We present the case of a 19-year-old man who initially had symptoms of pericarditis. He died 1 year after initial presentation.

Surgical biopsy of suspected interstitial lung disease is superior to radiographic diagnosis.

BACKGROUND: Different modalities are used to diagnose interstitial lung disease. We compared the effectiveness of minimally invasive surgical biopsy versus high-resolution computed tomography for the diagnosis of interstitial lung disease and report the mortality of the procedure. METHODS: We reviewed 194 patients undergoing video-assisted thoracoscopic lung biopsies for the suspicion of interstitial lung disease from January 2003 to February 2012 at Emory University. Demographics and patient characteristics were analyzed in addition to final diagnoses and clinical outcomes. RESULTS: Concordance of radiographic diagnosis with final diagnosis was poor, matching pathologic diagnosis in 15% of cases, and specific diagnoses were included in the radiographic differential in only 34% of cases. A specific diagnosis was made after surgical biopsy in 88% of cases. Overall mortality of surgical biopsy was 6.7% (13/194). Major risk factors for death were preoperative supplemental oxygen, ventilator dependence, and age (p < 0.0001, p < 0.0001, and p = 0.03, respectively). Among patients with ventilator dependence preoperatively, the mortality rate was 100% versus 4.8% in patients not ventilator dependent. All biopsy specimens were concordant 91% of the time, and the first two biopsy specimens were concordant 96% of the time. CONCLUSIONS: Surgical biopsy should remain the gold standard for diagnosis of interstitial lung disease. The mortality is low with proper patient selection. More than two surgical biopsy specimens may not be needed because the concordance rates among pathologic specimens are very high.

Short- and long-term outcomes in octogenarian patients undergoing off-pump coronary artery bypass grafting compared with on-pump coronary artery bypass grafting.

OBJECTIVE: : Coronary artery bypass grafting (CAB) on elderly patients presenting with multivessel coronary artery disease has become routine in modern day operating rooms. The aim of our study was to compare short- and long-term outcomes in octogenarian patients undergoing off-pump CAB (OPCAB) versus on-pump CAB (ONCAB). METHODS: : A propensity-adjusted, retrospective review of patients older than 80 years who underwent primary CAB from January 1996 to September 2008 at our institution's hospitals was performed. Nine hundred thirty-seven patients were divided into two groups: OPCAB (n = 540) or ONCAB (n = 397). A propensity score was calculated based on 29 preoperative risk factors to adjust for selection bias when comparing the groups for differences in death, stroke, myocardial infarction incidence, and their composite (major adverse cardiac events). Long-term survival status was determined by cross-referencing patient records with the Social Security Death Index. Logistic regression analysis and Cox proportional hazards analysis were used to determine group differences in short- and long-term survival, respectively, adjusted for the propensity score. Kaplan-Meier curves were fit to estimate 10-year survival. RESULTS: : The mean age (OPCAB: 82.9 ± 2.8 years vs ONCAB: 82.3 ± 2.4, P = 0.003) and male sex (OPCAB: 292/540, 54.1% vs ONCAB: 220/397, 55.4%, P = 0.68) were clinically similar between groups. Although the ejection fraction (OPCAB: 52.1 ± 12.5% vs ONCAB: 50.6 ± 13.1, P = 0.10) were similar between groups, the mean number of distal anastomoses [OPCAB: 2.7 ± 1.0 (median 3) vs ONCAB: 3.4 ± 0.9 (median 3), P < 0.001] were less in the OPCAB group. The median postoperative length of stay was 7 days for OPCAB group and 6 for the ONCAB group (P = 0.31). The Society of Thoracic Surgery predicted risk of in-hospital mortality was similar for OPCAB (5.4%) and ONCAB (5.3%) patients (P = 0.81). However, observed in-hospital mortality was improved for patients in the OPCAB group (OPCAB: 15/540, 2.8% vs ONCAB: 37/397, 9.3%, P = 0.007). Ten-year survival was similar between groups (OPCAB: 28.8% vs ONCAB: 26.3%, P = 0.22). CONCLUSIONS: : In this series, OPCAB reduced the incidence of in-hospital mortality compared with ONCAB. Long-term mortality was similar between groups.