Features and Outcomes of Females and Males Requiring Postcardiotomy Extracorporeal Life Support.

BACKGROUND: Although cardiogenic shock requiring extracorporeal life support (ECLS) after cardiac surgery is associated with high mortality, the impact of sex on outcomes of post-cardiotomy ECLS remains unclear with conflicting results in literature. We compare patient characteristics, in-hospital outcomes, and overall survival between females and males requiring post-cardiotomy ECLS. METHODS: This retrospective, multicentre (34 centres), observational study included adults requiring post-cardiotomy ECLS between 2000 and 2020. Pre-operative, procedural, and ECLS characteristics, complications, and survival were compared between females and males. Association between sex and in-hospital survival was investigated through mixed-Cox proportional hazards models. RESULTS: This analysis included 1823 patients [females:40.8%; median age:66.0 (interquartile range:56.2-73.0 years)]. Females underwent more mitral (females:38.4%, males:33.1%, p=0.019) and tricuspid (females:18%, males:12.4%, p<0.001) valve surgery, while males had more coronary artery surgery (females:45.9%, males:52.4%, p=0.007). ECLS implantation was more common intra-operatively in females (females:64.1%, males:59.1%) and post-operatively in males (females:35.9%, males:40.9%, p=0.036). Ventricular unloading (females:25.1%, males:36.2%, p<0.001) and intra-aortic balloon pump (females: 25.8%, males:36.8%, p<0.001) were most frequently used in males. Females suffered more post-operative right ventricular failure (females:24.1%, males:19.1%, p=0.016) and limb ischemia (females:12.3%, males:8.8%, p=0.23). In-hospital mortality was 64.9% in females and 61.9% in males (p=0.199) with no differences in 5-year survival (females:20%, 95%CI:17-23; males:24%, 95%CI:21-28;p=0.069). Crude hazard ratio for in-hospital mortality in females was 1.12 (95%CI: 0.99-1.27,p=0.069) and did not change after adjustments. CONCLUSIONS: This study demonstrates that females and males requiring post-cardiotomy ECLS have different pre-operative and ECLS characteristics, as well as complications, without a statistical difference in in-hospital and 5-year survival.

On-Support and Postweaning Mortality in Postcardiotomy Extracorporeal Membrane Oxygenation.

BACKGROUND: Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated. METHODS: The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year. RESULTS: In 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality. CONCLUSIONS: A discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.

Heterogeneity in Clinical Practices for Post-Cardiotomy Extracorporeal Life Support: a Pilot Survey from the PELS-1 Multicenter Study.

BACKGROUND: High-quality evidence for post-cardiotomy extracorporeal life support (PC-ECLS) management is lacking. This study investigated the real-world PC-ECLS clinical practices. METHODS: This cross-sectional, multi-institutional, international pilot survey explored center organization, anticoagulation management, left ventricular unloading, distal limb perfusion, PC-ECLS monitoring and transfusions practices. Twenty-nine questions were distributed among 34 hospitals participating in the Post-cardiotomy Extra-Corporeal Life Support Study. RESULTS: Of the 32 centers [16 low-volume (50%); 16 high-volume (50%)] that responded, 16 (50%) had dedicated ECLS specialists. Twenty-six centers (81.3%) reported using additional mechanical circulatory supports. Anticoagulation practices were highly heterogeneous: 24 hospitals (75%) reported using patient's bleeding status as a guide, without a specific threshold in 54.2% of cases. Transfusion targets ranged 7-10 g/dL. Most centers used cardiac venting on a case-by-case basis (78.1%) and regular distal limb perfusion (84.4%). Nineteen (54.9%) centers reported dedicated monitoring protocols including daily echocardiography (87.5%), Swan-Ganz catheterization (40.6%), cerebral near-infrared spectroscopy (53.1%) and multimodal assessment of limb ischemia. Inspection of the circuit (71.9%), oxygenator pressure drop (68.8%), plasma free hemoglobin (75%), d-dimer (59.4%), lactate dehydrogenase (56.3%) and fibrinogen (46.9%) are used to diagnose hemolysis and thrombosis. CONCLUSIONS: This study shows remarkable heterogeneity in clinical practices for PC-ECLS management. More standardized protocols and better implementation of available evidence are recommended.

The importance of timing in postcardiotomy venoarterial extracorporeal membrane oxygenation: A descriptive multicenter observational study.

OBJECTIVES: Postcardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intraoperatively or postoperatively based on indications, settings, patient profile, and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patient characteristics as well as in-hospital and long-term survival between intraoperative and postoperative ECMO. METHODS: The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support (PELS-1) study includes adults who required ECMO due to postcardiotomy shock between 2000 and 2020. We compared patients who received ECMO in the operating theater (intraoperative) with those in the intensive care unit (postoperative) on in-hospital and postdischarge outcomes. RESULTS: We studied 2003 patients (women: 41.1%; median age: 65 years; interquartile range [IQR], 55.0-72.0). Intraoperative ECMO patients (n = 1287) compared with postoperative ECMO patients (n = 716) had worse preoperative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1-3 days). Compared with intraoperative application, patients who received postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 19.7%; postoperative: 24.8%, P = .011), percutaneous coronary interventions (intraoperative: 1.8%; postoperative: 3.6%, P = .026), and had greater in-hospital mortality (intraoperative: 57.5%; postoperative: 64.5%, P = .002). Among hospital survivors, ECMO duration was shorter after intraoperative ECMO (median, 104; IQR, 67.8-164.2 hours) compared with postoperative ECMO (median, 139.7; IQR, 95.8-192 hours, P < .001), whereas postdischarge long-term survival was similar between the 2 groups (P = .86). CONCLUSIONS: Intraoperative and postoperative ECMO implantations are associated with different patient characteristics and outcomes, with greater complications and in-hospital mortality after postoperative ECMO. Strategies to identify the optimal location and timing of postcardiotomy ECMO in relation to specific patient characteristics are warranted to optimize in-hospital outcomes.

The Relation Between Obesity and Mortality in Postcardiotomy Venoarterial Membrane Oxygenation.

BACKGROUND: Obesity is an important health problem in cardiac surgery and among patients requiring postcardiotomy venoarterial extracorporeal membrane oxygenation (V-A ECMO). Still, whether these patients are at risk for unfavorable outcomes after postcardiotomy V-A ECMO remains unclear. The current study evaluated the association between body mass index (BMI) and in-hospital outcomes in this setting. METHODS: The Post-cardiotomy Extracorporeal Life Support (PELS-1) study is an international, multicenter study. Patients requiring postcardiotomy V-A ECMO in 36 centers from 16 countries between 2000 and 2020 were included. Patients were divided in 6 BMI categories (underweight, normal weight, overweight, class I, class II, and class III obesity) according to international recommendations. Primary outcome was in-hospital mortality, and secondary outcomes included major adverse events. Mixed logistic regression models were applied to evaluate associations between BMI and mortality. RESULTS: The study cohort included 2046 patients (median age, 65 years; 838 women [41.0%]). In-hospital mortality was 60.3%, without statistically significant differences among BMI classes for in-hospital mortality (P = .225) or major adverse events (P = .126). The crude association between BMI and in-hospital mortality was not statistically significant after adjustment for comorbidities and intraoperative variables (class I: odds ratio [OR], 1.21; 95% CI, 0.88-1.65; class II: OR, 1.45; 95% CI, 0.86-2.45; class III: OR, 1.43; 95% CI, 0.62-3.33), which was confirmed in multiple sensitivity analyses. CONCLUSIONS: BMI is not associated to in-hospital outcomes after adjustment for confounders in patients undergoing postcardiotomy V-A ECMO. Therefore, BMI itself should not be incorporated in the risk stratification for postcardiotomy V-A ECMO.

Minimally invasive approach: is this the future of aortic surgery?

Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-021-01258-2.

Endoscopic vein-graft harvesting in coronary artery bypass surgery: Tips and tricks.

Despite increased use of arterial grafts, the greater saphenous vein remains the most commonly used conduit in coronary artery bypass grafting. The use of less invasive techniques for vessel harvesting has gained interest in recent years, and, many studies have reported that endoscopic vein-graft harvesting reduces postoperative pain, the incidence of wound complications, and the length of hospital stay, as well as eliminating the need for a large longitudinal incision. Over the past decade, our cardiac surgery department has gained considerable experience (>1000 cases) with this endoscopic approach.  In this video tutorial, we demonstrate our endoscopic techniques for saphenous vein-graft harvesting using two widely used devices: the VirtuoSaph Endoscopic Vein Harvesting System from Terumo (Tokyo, Japan), an open tunnel system, and the VasoView System from Maquet Cardiovascular (Rastatt, Germany), a closed tunnel system.

Mini Bentall operation: technical considerations.

Bentall operation via median sternotomy has been largely shown to be safe and long-term efficacious and currently represents the "gold standard" intervention in patients presenting with aortic valve and root disease. However, over the last years, minimally invasive techniques have gained wider clinical application in cardiac surgery. In particular, minimally invasive aortic valve replacement through ministernotomy has shown excellent outcomes and becomes the first choice approach in numerous experienced centers. Based on these favorable results, ministernotomy approach has also been proposed for complex cardiac procedures such as aortic root replacement and arch surgery. Herein, we present our technique for minimally invasive Bentall operation using a ministernotomy approach.

Saphenous Vein Graft Wrapping by Nitinol Mesh: A Word of Caution.

BACKGROUND: Saphenous vein conduits are still used in a large proportion of coronary artery bypass graft (CABG) operations. A recently commercialized nitinol mesh seems to improve venous graft patency. The aim of this study was to control nitinol mesh vein graft patency in a series of isolated CABG patients by computed tomographic (CT) scan. METHODS: In 25 patients (mean age: 61.0 ± 9.65 years), operated for isolated CABG, the eSVS nitinol mesh (Kips Bay Medical Inc., Minneapolis, Minnesota, United States) was used to wrap one vein graft in each patient. Nitinol mesh vein graft was used to revascularize the right coronary (4 patients; 16%), the posterior descending (18 patients; 72%), and the obtuse marginal (3 patients; 12%) arteries. CT scans were performed at 1, 6, and 12 months postoperatively. RESULTS: The procedure was uneventful in all patients. CT controls showed an overall patency rate of 86.9, 42.7, and 34.1% at 1, 6, and 12 months, respectively. The 4 mm mesh had a significantly higher patency rate at 12 months (83.33%) than the 3.5 mm one which showed quite unsatisfactory results (20%) (p = 0.02). Patients with graft occlusion underwent stress testing which was mildly positive in two cases. One of them underwent a percutaneous revascularization. CONCLUSION: Despite promising early results, use of nitinol mesh for saphenous veins was disappointing in our experience. Further refinements are probably needed.

Conventional surgery results in patients originally referred for transcatheter aortic valve implantation.

AIMS: Transcatheter aortic valve implantation (TAVI) is increasingly considered as a viable alternative to conventional aortic valve replacement (AVR) in high-risk patients. Long-term results, however, are still scarce and medical community hesitates in enlarging indications to lower-risk patients. Moreover, available devices are expensive and a strict potential candidate selection is necessary. METHODS: From April 2008 to August 2012, a total of 212 patients, originally referred for percutaneous treatment, were thoroughly evaluated by the aortic team of our department in order to choose the optimal procedure. Of them, 55 patients (35 women; 20 men) were considered as still acceptable candidates for conventional AVR. RESULTS: Mean age was 80.7 ±â€Š4.7 years; mean additive and logistic Euroscore I were 9.7 ±â€Š1.8 and 17.8 ±â€Š9.5%, respectively. Mean Euroscore II was 7.9 ±â€Š5.5%. Mean New York Heart Association class was 2.9 ±â€Š0.5. The majority of patients (87.2%) presented a geriatric frailty score of 0-1. Four patients showed a heavily calcified ascending aorta, and five patients (9%) underwent reoperations. Hospital mortality was 10.9% (six patients). Mean follow-up was 535.9 ±â€Š407.4 days (range: 6-1365 days). Six other patients died during this period for a mean survival of 74.4 ±â€Š6.9% at 2 years. Mean New York Heart Association class at 1 year was 1.25 ±â€Š0.5 (P < 0.01 vs. preoperative value). CONCLUSION: AVR should be indicated with caution in high-risk patients originally referred for TAVI. Despite medium-term results being good, with excellent functional status, hospital mortality is not negligible.

Ten years' follow-up of single-surgeon minimally invasive reparative surgery for degenerative mitral valve disease.

OBJECTIVE: Granted that minimally invasive mitral valve (MV) surgery short-term results were found to be equivalent to those achieved with traditional sternotomy with respect to perioperative morbidity and echocardiographic outcomes, little is known about the long-term efficacy of this approach. This report analyzes a 10-year single-surgeon experience with minimally invasive MV surgery through a right minithoracotomy with peripheral cannulation and external aortic cross-clamping and MV repair (MVR) by direct vision. METHODS: We studied 179 patients (48% female) who underwent MVR between December 1999 and December 2010. Mean age was 40.2 ± 10.1 years (range, 15-67 years). One hundred seventy patients (95.0%) had degenerative diseases, and nine patients (5.0%) had endocarditic diseases. Repair techniques for degenerative disease with posterior leaflet prolapse (74 patients, 43.5%) consisted of quadrangular resection (QR) and annuloplasty (AP) combined with sliding plasty (49 patients, 58.1%); for anterior leaflet prolapse (28 patients, 16.5%) and bileaflet prolapse (66 patients, 38.8%), edge-to-edge repair (EE) and AP; in 2 patients (1.2%), annular dilatation alone consisting of AP. Repair techniques for endocarditic disease consisted of EE in six patients (66.7%), perforation closure in two patients (22.2%), and QR combined with AP in one patient (11.1%). RESULTS: All patients survived the operation and were discharged with MV regurgitation (MR) less than 2+/4+. At 10 years' follow-up, overall survival was 98.7% ± 1.2%, freedom from redo was 98.5% ± 1.1%, freedom from MR recurrence (>2+/4+) in QR and in EE repair were, respectively, 91.7% ± 2.2% and 90.0% ± 2.4% (P = not significant). The linearized rates of overall mortality, MR recurrence (>2+/4+), and redo at follow-up are 0.10% ± 0.10% per year, 0.63% ± 0.26% per year, and 0.21% ± 0.15% per year, respectively. CONCLUSIONS: Minimally invasive MVR can be performed with very good perioperative and long-term results. Freedom from MR greater than 2+/4+ recurrence for patients with QR is equivalent to that with EE repair in our patient cohort.

Atrial myxoma: a 25-year single-institutional follow-up study.

OBJECTIVE: A single-institutional study on atrial myxoma. Patient data and data obtained from the survivors during follow-up were reviewed. METHODS: We studied 109 patients (61.5% female) who underwent surgical excision of atrial myxoma between January 1980 and December 2005. Mean age at the time of surgery was 60 +/- 14 years (range 1-83 years). Overall survival and atrial myxoma recurrence were determined by Kaplan-Meier analysis. Linearized rates of recurrence at follow-up are reported. RESULTS: One hundred and two (93.6%) of the 109 tumours were found in the left atrium. Comparative mean age distribution revealed a significant difference between patients operated on between 1980 and 1992 and patients operated on between 1993 and 2005 (55 +/- 15 and 63 +/- 13 years, respectively; P < 0.05). All patients survived the operation. Three patients were lost to follow-up. The 15-year and 25-year survival rates were 91 +/- 4% and 72 +/- 12%, respectively. Survival of patients after myxoma removal did not significantly differ from the expected survival of the general population. Recurrent myxomas developed in two patients (mean age 50 +/- 7 years) with a 25-year freedom from reoperation of 96 +/- 3% and a linearized rate of 0.17 +/- 0.12%/year. CONCLUSIONS: Myxomas tend to be observed in a more elderly and higher-risk population, often at an early stage. The extended follow-up of patients with intracardiac myxomas shows that surgical excision of such tumours is curative with low mortality and good long-term outcome.

Mitral valve repair for degenerative disease: is pericardial posterior annuloplasty a durable option?

OBJECTIVE: Biological and prosthetic rings are available for supporting mitral valve repair (MVR). Contrasting data are reported on the durability of pericardial ring annuloplasty. This retrospective study was undertaken to assess the durability of MVR for degenerative regurgitation with posterior annuloplasty performed with glutaraldehyde-treated autologous pericardium. METHODS: From August 1995 through December 2000, 133 patients underwent mitral repair for degenerative regurgitation (86 men, age 62.9+/-11.5 years). Thirty patients (22.6%) underwent combined coronary artery bypass graft and fourteen (10.5%) underwent tricuspid annuloplasty. Associated aortic disease, previous cardiac surgery and endocarditis were considered exclusion criteria. RESULTS: Seventy-seven patients (57.9%) received a Carpentier-Edwards ring and 56 received (42.1%) an autologous pericardium ring. Thirty-day mortality was 3.8%. Mean follow-up, 98.3% complete, was of 35.6+/-18.7 months. Five-year freedom from reoperation and recurrence of mitral regurgitation> or =3+/4+ was significantly higher in the prosthetic ring group (90.1% - CL90%: 81.9-98.3%) compared with the pericardial ring group (62.6% - CL90%: 43.1-82.1%; P=0.027). Prosthetic ring implantation (P=0.004; RR=0.11) and preoperative New York Heart Association (NYHA) class< or =II (P=0.011; RR=0.16) were independently related to a lower risk of reoperation and recurrence of mitral regurgitation> or =3+/4+, by multivariate analysis. Five-year overall survival was 91.4% (CL90%: 87.9.7-95%). A higher preoperative left ventricular end-diastolic diameter (P=0.006; RR=1.17) and the severity of associated coronary artery disease (P=0.021; RR=2.00) were independent predictive factors for poor survival by multivariate analysis. CONCLUSIONS: Posterior pericardial annuloplasty can jeopardize reproducibility and durability of MVR for degenerative regurgitation.

Biochemical evaluation of vacuum-assisted venous drainage: a randomized, prospective study.

AIMS OF THE STUDY: In this prospective, randomized study, we investigate the potential advantages of vacuum-assisted venous drainage (VAVD), compared to gravitational drainage (GD), in patients undergoing first-time coronary artery bypass graft (CABG) surgery, concerning biochemical markers of organ and blood cell damage. MATERIALS AND METHODS: Seventy-two consecutive patients were randomized into two groups ['Vacuum' (VAVD) n=36; 'Not vacuum' (GD) n=36]. VAVD was achieved using a wall vacuum source and with a suction regulator connected to the vent port of the hardshell venous reservoir. In the VAVD group, we used 28-French venous cannulas, and 36-French in the GD group. In the VAVD group, we measured arterial perfusion flow (APF) and the venous reservoir volume (VRV) with and without vacuum application just after starting extracorporeal circulation (ECC). Six blood samples were drawn at different times before, during and after ECC. Routine blood tests were performed to evaluate hemolysis, and hepatic and renal function. RESULTS: The two groups were similar in terms of preoperative and operative characteristics. There were no significant differences in biochemical markers of organ function or hemolysis between the two groups. In the VAVD patients, platelet count was higher at 24 h after the end of the operation (VAVD 151.77+/-50.28 microl versus Not vacuum 124.93+/-41.60 microl, p=0.028). With the narrower venous cannulas (28-French), only VAVD achieved a satisfactory APF (VAVD 2.35+/-0.38 l/min/m2 versus GD 1.88+/-0.27 l/min/m2, p=0.002), with a larger VRV (VAVD 1091.67+/-421 ml versus GD 808.33+/-284.31 ml, p=0.025). CONCLUSION: Vacuum-assisted venous drainage is a technique comparable to gravitational drainage with regard to hemolysis and organ perfusion. It allows better perfusion flow and heart decompression with smaller venous cannulas. This study suggests reduced platelet consumption with VAVD.