Development of a Risk Score for Long-term Survival and MACCE After Coronary Artery Bypass Grafting Surgery.

OBJECTIVE: To develop risk scoring models predicting long-term survival and major adverse cardiovascular and cerebrovascular events (MACCE) including myocardial infarction and stroke after coronary artery bypass grafting (CABG). METHODS: All-consecutive 4,821 patients undergoing isolated CABG at Lankenau between 01/2005-07/2021 were included. MACCE was defined as all-cause mortality+myocardial infarction (MI)+stroke. Variable selection for both outcomes was obtained using a double selection logit Lasso with adaptive selection. Models performance was internally evaluated by calibration and accuracy using bootstrap cross-validation. Mortality and MACCE were compared among patients split into three groups based on the predicted risk scores for all-cause mortality and MACCE. An external validation of our database was performed with 665 patients from the University of Brescia, Italy. RESULTS: Pre-operative risk predictors were found to be predictors for all-cause mortality and MACCE. In addition, being of African American ethnicity is a significant predictor for MACCE after isolated CABG. The AUC which measures the discrimination of the models were 80.4%, 79.1%, 81.3%, and 79.2% for mortality at 1,2,3, and 5 years follow-up. The AUC for MACCE were 75%, 72.5%, 73,8%, and 72.7% at 1, 2, 3, and 5-years follow-up. For external validation, AUC for all-cause mortality and MACCE at 1, 2, 3, and 5 years was 73.7%, 70.8%, 68.7%, and 72.2% and 72.3%, 68.2%, 65.6%, 69.6%, respectively. CONCLUSIONS: The Advanced (AD) Coronary Risk Score for All-Cause Mortality and MACCE provide good discrimination of long-term mortality and MACCE after isolated CABG. External validation observed a more AUC's above 70%.

Totally endoscopic, robotic-assisted tricuspid valve repair and biatrial CryoMAZE.

We describe in detail our technique for totally endoscopic, robotic-assisted tricuspid valve repair for iatrogenic tricuspid regurgitation and biatrial cryoMAZE.

Assessment of online information on robotic cardiac and thoracic surgery.

Online health resources are important for patients seeking perioperative information on robotic cardiac and thoracic surgery. The value of the resources depends on their readability, accuracy, content, quality, and suitability for patient use. We systematically assess current online health information on robotic cardiac and thoracic surgery. Systematic online searches were performed to identify websites discussing robotic cardiac and thoracic surgery. For each website, readability was measured by nine standardized tests, and accuracy and content were assessed by an independent panel of two robotic cardiothoracic surgeons. Quality and suitability of websites were evaluated using the DISCERN and Suitability Assessment of Materials tools, respectively. A total of 220 websites (120 cardiac, and 100 thoracic) were evaluated. Both robotic cardiac and thoracic surgery websites were very difficult to read with mean readability scores of 13.8 and 14.0 (p = 0.97), respectively, requiring at least 13 years of education to be comprehended. Both robotic cardiac and thoracic surgery websites had similar accuracy, amount of content, quality, and suitability (p > 0.05). On multivariable regression, academic websites [Exp (B)], 2.25; 95% confidence interval [CI], 1.60-3.16; P < 0.001), and websites with higher amount of content [Exp (B)],1.73; 95% CI, 1.24-2.41; P < 0.001) were associated with higher accuracy. There was no association between readability of websites and accuracy [Exp (B)], 1.04; 95% CI, 0.90-1.21; P = 0.57). Online information on robotic cardiac and thoracic surgery websites overestimate patients' understanding and require at least 13 years of education to be comprehended. As website accuracy is not associated with ease of reading, the readability of online resources can be improved without compromising accuracy.

Extremely Long-Term Follow-Up of Dr William Glenn's Original Patient Cohort With Superior Cavopulmonary Anastomosis (1958-1990).

BACKGROUND: Historically, Dr William Glenn performed the first classic superior cavopulmonary anastomosis in a seven-year-old child at Yale in 1958. By 1990, this operation was performed consecutively in over 90 patients. With over 60 years of follow-up, this is the longest survival record of early Glenn patients from the first 30 years. METHODS: We performed a single center, retrospective evaluation of patients undergoing a Glenn operation. A collected list of surviving patients, previously updated in 1988, included demographics, age at procedure, and underlying diagnosis. Follow-up data were obtained in May 2022 using electronic medical records to determine survival, age of survivors, and age of deceased. RESULTS: Ninety-five patients underwent the Glenn operation from 1958 to 1990: 58.9% (n = 56) were male and 41.1% (n = 39) female. Fifteen patients were lost to follow-up, but 12 were alive in 1988. Sixty patients were deceased (68.1%), with an average age of 33.5 ± 18.3(range, 2-78, excluding seven early deaths) years. The oldest patient who passed away was a 78-year-old male with tetralogy of Fallot. Twenty patients remain alive, with an average age of 47.5 (range, 32-66) years. Four patients who are still alive today (20% survivors) are older than 60 years. CONCLUSIONS: Since Dr Glenn's original operation, the technique, timing, and indications have been modified (ie, bidirectional Glenn) to adapt to the current era. By following this initial group of patients, we can approach completion of the survival rates for adult congenital patients who were some of the first pediatric patients to receive this ground-breaking palliative procedure.

Mild aortic insufficiency following transcatheter aortic valve replacement: A systematic review and meta-analysis.

BACKGROUND: Post-procedural aortic insufficiency (AI) continues to be prevalent following transcatheter aortic valve replacement (TAVR). While several studies have assessed the outcomes of moderate-severe AI following TAVR, the incidence, predictors, and outcomes of mild AI remain unclear. METHODS: A systematic literature review was performed to identify studies reporting on mild AI following TAVR. The primary outcome was pooled incidence of post-TAVR mild AI. Secondary outcomes included pooled incidence of mild AI at 30 days and long term. The pooled incidence of midterm mortality in patients with post-TAVR mild AI was also evaluated. The random effect generalized linear mixed-effects model with logit-transformed proportions and Hartung-Knapp adjustment was used to calculate pooled incidence rates. Meta-regression was performed to identify predictors of mild AI. RESULTS: The pooled analysis included 19,241 patients undergoing TAVR across 50 studies. The mean age of patients ranged from 73 to 85 years, and female patients ranged from 20.0% to 83.3%. The overall pooled incidence of post-TAVR mild AI was 56.1% (95% confidence interval [CI] 0.31-0.64). The pooled incidence of mild AI at 30 days was 33.7% (95% CI 0.12-0.37). At mean follow-up of 1.15 years, the pooled incidence of mild AI was 37.0% (95% CI 0.16-0.45). The overall pooled incidence of Midterm mortality (mean follow-up 1.22 years) in patients with mild AI was 14.8% (95% CI 0.10-0.25). At meta-regression, none of the explored variables correlated with a difference in mild AI incidence. CONCLUSIONS: In published studies to date, 50% of patients undergoing TAVR develop mild AI postoperatively. In 37% of patients, this persists in long term. Though the incidence of AI is likely improving with newer generation TAVR valves, the prevalence and outcomes of mild AI should be closely monitored as TAVR volume and indications expand to younger patients with long life expectancy. The long-term outcomes of mild AI remain unclear. Further dedicated studies on post-TAVR mild AI are needed.

Multidisciplinary Management of Opioid Use-Related Infective Endocarditis: Treatment, QTc Values, and Cardiac Arrests due to Ventricular Fibrillation.

(1) Background: The opioid epidemic has led to an increase in cardiac surgery for infective endocarditis (IE-CS) related to injection use of opioids (OUD) and other substances and a call for a coordinated approach to initiate substance use disorder treatment, including medication for OUD (MOUD), during IE-CS hospitalizations. We sought to determine the effects of the initiation of a multi-disciplinary endocarditis evaluation team (MEET) on MOUD use, electrocardiographic QTc measurements and cardiac arrests due to ventricular fibrillation (VF) in patients with OUD. (2) Methods and Results: A historical group undergoing IE-CS at Yale-New Haven Hospital prior to MEET initiation, Group I (43 episodes of IE-CS, 38 patients) was compared to 24 patients undergoing IE-CS after MEET involvement (Group II). Compared to Group l, Group II patients were more likely to receive MOUD (41.9 vs. 95.8%, p < 0.0001), predominantly methadone (41.9 vs. 79.2%, p = 0.0035) at discharge. Both groups had similar QTcs: approximately 30% of reviewed electrocardiograms had QTcs ≥ 470 ms and 17%, QTcs ≥ 500 ms. Cardiac arrests due to VF were not uncommon: Group I: 9.3% vs. Group II: 8.3%, p = 0.8914. Half occurred in the 1-2 months after surgery and were contributed to by pacemaker malfunction/ management and half were related to opioid use. (3) Conclusions: MEET was associated with increased MOUD (predominantly methadone) use during IE-CS hospitalizations without an increase in QTc prolongation or cardiac arrest due to VF compared to Group I, but events occurred in both groups. These arrests were associated with pacemaker issues or a return to opioid use. Robust follow-up of IE-CS patients is essential, as is further research to clarify the longer-term effects of MEET on outcomes.

Trans-sternotomy, snare-assisted thoracic endovascular aortic repair for redirection of a migrated elephant trunk.

The two-stage elephant trunk (ET) and thoracic endovascular aortic repair technique for type A and B aortic dissection can result in complications between the two stages. We have presented the case of a patient with an acute-on-chronic type B aortic dissection complicated by ET kinking and migration into the false lumen. We used a hybrid approach consisting of a first stage (retrograde thoracic endovascular aortic repair) and a second stage ("body floss" with antegrade thoracic endovascular aortic repair) to successfully reposition the ET back into the true lumen.

De-Airing Maneuvers After Minimally Invasive and Robotic-Assisted Intracardiac Procedures.

In the setting of minimally invasive and robotic-assisted intracardiac procedures, de-airing requires further technical considerations due to limited access to the pericardial space and the subsequent difficulty of directly manipulating the heart. We summarize the technical steps for de-airing according to different cannulation strategies for minimally invasive and robotic-assisted intracardiac procedures.

A robotic-assisted approach to sliding plasty, neochordoplasty, and annuloplasty in a technically complex mitral valve repair.

In experienced hands, complex mitral valve repair can be safely and effectively performed in a totally endoscopic, robotic-assisted manner. We present a technically complex case of a 76-year-old man with severe, symptomatic mitral regurgitation due to Barlow's disease, moderate-to-severe tricuspid regurgitation, and atrial fibrillation.

Respect versus resect approaches for mitral valve repair: A study-level meta-analysis.

Mitral valve repair (MVr) restores leaflets coaptation while preserving the patient's own valve. The two main techniques are: (a) chordal replacement ("respect approach"), whereby artificial neochordae are used to resuspend prolapsed segments of the affected leaflet - and (b) leaflet resection ("resect approach"), whereby diseased leaflet segment is resected, and the remaining segments are sutured together. Both techniques of MVr are associated with better long-term results, fewer valve-related complications and lower mortality when compared with mitral valve replacement (MVR). They also restore quality of life and improve survival to rates equivalent to those of the general population. We performed a meta-analysis to pool data of clinical studies that compared outcomes of MVr stratified by the surgical technique. Seventeen studies accounting for 6,046 patients fulfilled our eligibility criteria. The "respect approach" outperformed the "resect approach" with lower permanent pacemaker implantation rates and lower mean gradients. Despite any possible advantages of one technique over the other, which approach is best for each patient must be decided on a case-by-case basis and more long-term follow-up data are warranted.

Spinal cord protection in open and endovascular approaches to thoracoabdominal aortic aneurysms.

Despite advancements in surgical and postoperative management, spinal cord injury has been a persistent complication of both open and endovascular repair of thoracoabdominal and descending thoracic aortic aneurysm. Spinal cord injury can be explained with an ischemia-infarction model which results in local edema of the spinal cord, damaging its structure and leading to reversible or irreversible loss of its function. Perfusion of the spinal cord during aortic procedures can be enhanced by several adjuncts which have been described with a broad variety of evidence in their support. These adjuncts include systemic hypothermia, cerebrospinal fluid drainage, extracorporeal circulation and distal aortic perfusion, segmental arteries reimplantation, left subclavian artery revascularization, and staged aortic repair. The Authors here reviewed and discussed the role of such adjuncts in preventing spinal cord injury from occurring, pinpointing current evidence and outlining future perspectives.

Pacemaker implantation following tricuspid valve annuloplasty.

Objective: Tricuspid annuloplasty is associated with increased risk of atrioventricular block and subsequent implantation of a permanent pacemaker. However, the exact incidence of permanent pacemaker, associated risk factors, and outcomes in this frame remain debated. The aim of the study was to report permanent pacemaker incidence, risk factors, and outcomes after tricuspid annuloplasty from nationwide databases. Methods: By using data from multiple Swedish mandatory national registries, all patients (n = 1502) who underwent tricuspid annuloplasty in Sweden from 2006 to 2020 were identified. Patients who needed permanent pacemaker within 30 days from surgery were compared with those who did not. The cumulative incidence of permanent pacemaker implantation was estimated. A multivariable logistic regression model was fit to identify risk factors of 30-day permanent pacemaker implantation. The association between permanent pacemaker implantation and long-term survival was evaluated with multivariable Cox regression. Results: The 30-day permanent pacemaker rate was 14.2% (214/1502). Patients with permanent pacemakers were older (69.8 ± 10.3 years vs 67.5 ± 12.4 years, P = .012). Independent risk factors of permanent pacemaker implantation were concomitant mitral valve surgery (odds ratio, 2.07; 95% CI, 1.34-3.27), ablation surgery (odds ratio, 1.59; 95% CI, 1.12-2.23), and surgery performed in a low-volume center (odds ratio, 1.85; 95% CI, 1.17-2.83). Permanent pacemaker implantation was not associated with increased long-term mortality risk (adjusted hazard ratio, 0.74; 95% CI, 0.53-1.03). Conclusions: This nationwide study demonstrated a high risk of permanent pacemaker implantation within 30 days of tricuspid annuloplasty. However, patients who needed a permanent pacemaker did not have worse long-term survival, and the cumulative incidence of heart failure and major adverse cardiovascular events was similar to patients who did not receive a permanent pacemaker.