Treatment Adherence Rates and Long-Term Mortality in a Quaternary Multidisciplinary Heart Team: An Observational Cohort.

BACKGROUND: A multidisciplinary heart team (HT) approach to patients with complex coronary artery disease has a class IB recommendation, yet there are limited data on adherence to HT treatment recommendations and long-term clinical follow-up. The objective of this study was to assess adherence rates to HT recommendations and assess long-term mortality rates among patients with complex CAD. METHODS AND RESULTS: Six hundred eighty-four sequential HT cases for complex coronary artery disease from January 2015 to May 2017 were reviewed. After excluding cases with significant comorbid valve disease, baseline characteristics were compared based on HT treatment recommendations: optimal medical therapy, percutaneous coronary intervention, and coronary artery bypass grafting. Adherence rates were manually extracted, and 5-year mortality rates were obtained from the Michigan Death Registry. Seventy-two percent of 405 included patients were men (mean age 66±11 years), with high rates of medical comorbidities. Estimated surgical risk scores were lowest in the coronary artery bypass grafting group. Optimal medical therapy was recommended in 138 patients (34%), percutaneous coronary intervention in 95 (23%), and coronary artery bypass grafting in 172 (42%). Adherence to HT recommendations across groups was high (96%) and did not differ between treatment groups. Over 5 years of follow-up, there were 119 deaths, resulting in a cumulative mortality rate of 29%. CONCLUSIONS: In the largest HT cohort in the United States to date, high rates of adherence to HT recommendations were observed among high-risk patients with coronary artery disease. High rates of adherence to HT recommendations were observed irrespective of treatment group recommendation, suggesting that HT recommendations were individualized and acceptable to both patients and physicians alike.

Four-year follow-up of outcomes of the hybrid epicardial-endocardial ablation: A single-center experience.

BACKGROUND: The CONVERGE trial demonstrated that hybrid epicardial and endocardial ablation was more effective than catheter ablation for the treatment of persistent atrial fibrillation (AF) at 1 year. Long-term real-world outcome data are scarce. OBJECTIVE: We described a single-center experience by evaluating the long-term effectiveness and safety of hybrid epicardial-endocardial ablation. METHODS: This is a retrospective single-center study. Patients were followed up to 4 years. The primary end point was the rate of AF recurrence up to 4 years postablation. Secondary end points included reduction in antiarrhythmic therapy use, the effect of the ligament of Marshall removal, epicardial posterior wall, 3-dimensional mapping during epicardial ablation, and left atrial appendage exclusion as adjunct intraoperative interventions for AF recurrence. RESULTS: Of the 170 patients, 86.5% had persistent AF and 13.5% had long-standing persistent AF. AF-free survival was 87.6% at 1 year, 76.9% at 2 years, 70.4% at 3 years, and 59.3% at 4 years. Antiarrhythmic drug use was 87.6% at baseline and reduced to 21%, 20.6%, 18%, and 14.1% at year 1, 2, 3, and 4, respectively (P < .01 for all). Three-dimensional epicardial mapping showed a significant reduction in combined recurrence from 42% to 25% over 4 years of follow-up (P = .023). Ligament of Marshall and left atrial appendage exclusion showed numerical reduction in AF recurrence from 35% to 26% (P = .49) and from 44% to 30% (P = .07). CONCLUSION: The hybrid convergent procedure reduces AF recurrence and the need for antiarrhythmic drugs and, while maintaining a good safety profile, for the treatment of persistent and long-standing persistent AF.

Randomized Feasibility Trial of Prophylactic Radiofrequency Ablation to Prevent Atrial Fibrillation after Cardiac Surgery.

OBJECTIVE: Evaluate the feasibility of prophylactic radiofrequency isolation of the pulmonary veins, with left atrial appendage amputation, to reduce the incidence of postoperative atrial fibrillation (POAF) after cardiac surgery in patients aged 70 and older. METHODS: The Federal Food and Drug Administration granted an investigational device exemption to utilize a bipolar radiofrequency clamp for prophylactic pulmonary vein isolation in a limited, feasibility trial. Sixty-two patients without prior dysrhythmias, were prospectively randomized to undergo either their index cardiac surgical procedure, or bilateral pulmonary vein isolation and left atrial appendage amputation during their cardiac operation. The primary outcome was occurrence of in-hospital POAF. Subjects were on 24-hour telemetry until discharge. Dysrhythmias, any episode of atrial fibrillation > 30 seconds, were confirmed by electrophysiologists blinded to the study. RESULTS: Sixty patients, mean age 75 years and mean CHA2DS2-VASc score 4, were analyzed. Thirty-one patients randomized to control and twenty-nine to the treatment group. Majority of cases in each group were isolated CABG. No perioperative complications related to the treatment procedure, need for permanent pacemaker, or mortality occurred. The in-hospital incidence of POAF was 55% (17/31) in the control group and 7% (2/29) in the treatment group. (p<0.001) The control group had a significantly higher requirement for antiarrhythmic medications at discharge, 45% (14/31) vs 7% (2/29) in the treatment group (p<0.001). CONCLUSIONS: Prophylactic radiofrequency isolation of the pulmonary veins with left atrial appendage amputation, during the primary cardiac surgical operation, reduced the incidence of POAF in patients 70 years and older with no history of atrial arrhythmias.

Long-term outcomes of etiology specific annuloplasty ring repair of ischemic mitral regurgitation.

BACKGROUND: Reductive annuloplasty repair of ischemic mitral regurgitation (IMR) is associated with high rates of recurrent MR, which may be improved with etiology-specific annuloplasty rings. METHODS: From October 2005 to May 2015, 128 consecutive patients underwent repair of IMR with the GeoForm ring. Clinical data was extracted from our local Society of Thoracic Surgeons database and electronic medical records. Mortality data was obtained from the Michigan State Social Security Death Index. RESULTS: The average age of patients was 65±11 years with mean pre-op left ventricular ejection fraction (LVEF) of 30%±10% and MR grade of 3.1±0.9 (0-4+). Thirty-day mortality was 4.7%, rate of renal failure 7.9%, rate of atrial fibrillation 27.3%, and no strokes were observed. Of the surviving patients, 89% (109/122) had a follow-up echocardiogram beyond 1 month with a mean echocardiographic follow-up of 59±39 months. LVEF improved from 30%±10% to 38%±14%, P<0.001) while end-diastolic (5.9±0.0 to 5.3±0.9 cm, P<0.001) and end-systolic (5.0±1.0 to 4.4±1.1 cm, P<0.001) left ventricular (LV) diameters decreased, as compared to pre-operative values. Seven patients were found to have recurrent moderate or greater IMR in follow-up to 10 years with three being due to ring dehiscence. One-, 5-, and 10-year freedom from recurrent moderate or severe IMR was 98%, 94%, and 80% respectively. One-, 5-, and 10-year survival was 91%, 77%, and 44%, respectively. CONCLUSIONS: Overall, etiology-specific ring repair of IMR was associated with low rates of recurrent MR on long-term follow-up, coupled with significant LV reverse remodeling and improvement in ejection fraction.

Del Nido cardioplegia in isolated adult coronary artery bypass surgery.

BACKGROUND: Del Nido cardioplegia (DC) offers prolonged single-dose myocardial protection in pediatric cardiac surgery. We set out to evaluate the efficacy of DC in adult patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: From January 2012 to October 2017, 851 consecutive isolated CABG surgeries were performed by 2 study surgeons at our center with blood cardioplegia (BC, n = 350), used from January 2012 to April 2014, and DC (n = 501), used from May 2014 to October 2017. Propensity matching was used to yield 325 well-matched pairs. Clinical data were extracted from our local Society of Thoracic Surgeons database and mortality data from the Michigan State Social Security Death Index. RESULTS: Single-dose administration was used in 83% (417/501) of patients receiving DC. In propensity-matched groups, postoperative median troponin T levels (0.28 [0.16-0.59] ng/mL vs 0.46 [0.27-0.81] ng/mL; P < .01) were lower for patients receiving DC, and no difference in ejection fraction on postoperative echocardiography was observed (54 ± 12% and 53 ± 13% for BC and DC, respectively; P = .36). Perioperative outcomes were similar except for greater rate of atrial fibrillation (33% vs 23%; P = .01) in the DC group. Subgroup analyses revealed equivalent myocardial protection and clinical outcomes in patients with age ≥75 years, left ventricular ejection fraction ≤35%, left main disease, or Society of Thoracic Surgeons score ≥2.5%. Four-year survival did not differ between patients undergoing BC or DC. CONCLUSIONS: The current study revealed noninferior myocardial protection and clinical outcomes with DC versus BC in both routine and greater-risk patients undergoing isolated CABG. DC demonstrated the feasibility of single-dose administration for isolated CABG surgery. Larger randomized studies are needed to further explore the safety and efficacy of DC in adult cardiac surgery with longer crossclamp times.

Long-Term Outcomes of Mosaic Versus Perimount Mitral Replacements: 17-Year Follow-Up of 940 Implants.

BACKGROUND: The objective of this study was to compare long-term outcomes of Mosaic (Medtronic, Minneapolis, MN) porcine mitral valves to Carpentier-Edwards (Edwards Lifesciences, Irving, CA) bovine pericardial mitral valves. METHODS: From 2001 through 2017 at a single institution, 940 patients received a mitral bioprosthesis, of which 463 (49.3%) were porcine and 477 (50.7%) were bovine pericardial. Retrospective review of the procedure and the postoperative clinical course, including echocardiography, through August 2018 were analyzed. All consecutive mitral valve replacements over the study period were included. Follow-up was 99% (929 patients) complete for a total of 6045 patient-years (mean, 6.4 ± 4.5 years). A propensity-matched cohort of 802 mitral bioprosthesis was used for outcome analyses. RESULTS: Operative mortality of the 940 patients was 5.4% (n = 51) and incidence of postoperative stroke was 2.1% (n = 20). Overall survival of the propensity-matched patients at 10 and 15 years was 49.7% (95% confidence interval [CI] 45.5%-53.7%) and 23.3% (95% CI 17.9%-29.3%), respectively. Survival at 15 years was 24.0% (95% CI 18.0%-30.5%) for porcine and 16.5% (95% CI 5.5%-32.6%) for bovine implants, which was not significantly different (P = .67). Overall cumulative incidence for reoperative structural valve deterioration at 15 years was 7.9% (95% CI 4.7%-12.3%) for porcine valves versus 13.2% (95% CI 8.1%-19.5%) for pericardial valves (P < .001). For patients age younger than 65 years, structural valve deterioration at 15 years was 15.8% (95% CI 7.4%-27.0%) versus 30.2% (95% CI 15.1%-46.8%) for porcine and pericardial valves, respectively (P = .009). Overall average time to reoperation for structural valve deterioration for porcine valves was 11.1 ± 2.3 years vs 6.8 ± 2.3 years for bovine pericardial valves (P < .001). CONCLUSIONS: In long-term follow-up, of patients younger than 65 years of age undergoing mitral valve replacement, bovine pericardial valves experienced earlier and more frequent structural valve deterioration than porcine valves.

Use of an Automated Suture Fastening Device in Minimally Invasive Aortic Valve Replacement.

BACKGROUND: Minimally invasive aortic valve replacement (mAVR) is gaining clinical acceptance; however, it is associated with increased operative times because of the limited surgical field and access. The Cor-Knot (CK; LSI Solutions, Victor, NY) is an automated fastening device designed to facilitate suture fastening, but clinical data in mAVR are lacking. METHODS: From May 2014 to February 2017, 92 patients underwent mAVR at Spectrum Health in Grand Rapids, Michigan; 39 valves were secured with manually tied sutures, and 53 valves were entirely secured with the CK device. Preoperative characteristics and 30-day outcomes data were extracted from the local The Society of Thoracic Surgeons database and the patients' electronic medical records. Survival data were obtained from the Michigan State Social Security Death Index. RESULTS: No significant differences in preoperative characteristics were noted between the two groups. Aortic cross-clamp time (72 ± 12 minutes vs 82 ± 15 minutes; p = 0.001) was significantly shorter with CK. There was no difference in the rate of postoperative mortality (0% vs 0%), stroke (0% vs 1.9%), atrial fibrillation (28% vs 33%), renal failure (0% vs 3.8%), or pacemaker implantation (5.1% vs 5.7%) between patients with manually tied sutures and patients with sutures fastened with the CK. Valve function on postoperative echocardiography and 1-year patient survival rates were similar. CONCLUSIONS: In mAVR, the CK device was associated with reduced aortic cross-clamp time while providing equivalent clinical outcomes. Larger studies are needed to confirm the efficacy, safety, and cost-effectiveness of the CK device in minimally invasive aortic valve surgery.

Single-dose del Nido Cardioplegia in Minimally Invasive Aortic Valve Surgery.

del Nido cardioplegia (DC) offers prolonged cardiac protection with single-dose administration and has been shown to be safe in adult CABG surgery. We set out to evaluate the efficacy of cardiac protection and clinical outcomes of DC versus standard blood cardioplegia (BC) in minimally invasive aortic valve surgery. From August 2011 to May 2016, 178 patients underwent minimally invasive aortic valve replacement (mini-AVR) with BC (n = 101) or DC (n = 77). Ministernotomy or right minithoracotomy was utilized for surgical access. Clinical patient characteristics and data were extracted from our local Society of Thoracic Surgeons (STS) database and the electronic medical record. Patients were propensity matched for age, gender, body mass index, valve size and type, STS score, surgical access, preop creatinine, diabetes, and chronic obstructive pulmonary disease, yielding 63 well-matched pairs. There was no difference in patient age, preoperative creatinine, body mass index, diabetes, chronic obstructive pulmonary disease, or STS score between BC and DC before or after propensity matching. BC patients received both anterograde and retrograde cardioplegias in multiple doses, whereas DC was delivered almost entirely anterograde with 95% of the patients (73/77) receiving a single dose only. DC was associated with decreased cardiopulmonary bypass time (108 ± 24 vs 135 ± 43 minutes, P = 0.001) and aortic cross-clamp time (80 ± 16 vs 102 ± 30 min, P = 0.001) and maximal glucose levels during cardiopulmonary bypass (165 ± 39 vs 202 ± 49 mg/dL, P = 0.001), whereas troponin T level did not differ between DC and BC (0.3 ± 0.29 vs 0.44 ± 1.7 ng/mL, P = 0.7). Preoperative ejection fraction did not change in either BC (64% ± 12% vs 61% ± 10%, P = 0.09) or DC (58% ± 14% vs 57% ± 14%, P = 0.4) after AVR. In minimally invasive AVR surgery, DC provided equivalent myocardial protection and clinical outcomes to BC while simplifying cardioprotective regimen and reducing aortic cross-clamp time. DC was associated with lower cardiopulmonary bypass glucose levels and demonstrated the feasibility of a single-dose administration.

WITHDRAWN: Single-dose del Nido cardioplegia in minimally invasive aortic valve surgery.

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Aortic valve replacement in octogenarians with prior cardiac surgery.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been advocated for very elderly patients with aortic stenosis, and prior cardiac surgery as a less invasive treatment option. Although surgical aortic valve replacement (AVR) is safe and effective in selected elderly patients, the perioperative and mid-term outcomes of AVR in very elderly with prior cardiac surgery are unknown. METHODS: The Society of Thoracic Surgeons (STS) Database at our center enrolled 3,735 patients after AVR since 1997. In this time interval, we identified 61 patients 80 years and older who underwent AVR for severe AS or failed aortic bioprosthesis after having prior cardiac surgery. All clinical parameters were derived from the STS database. Follow-up mortality was assessed using the Social Security Death Index. RESULTS: The average age of the patients was 83 ± 2 years, 77% were male, and 75% underwent an isolated coronary artery bypass graft (CABG) as their first cardiac procedure. The mean ejection fraction was 0.53 ± 0.13. The CABG was performed concurrently in 49% of patients at the time of redo sternotomy and AVR. Stented bioprosthesis was implanted in 61% of patients and stentless in 39%. Perioperative mortality was 1.6% (1 of 61). One, 3, 5, and 7 year survival rates were 85%, 69%, 63%, and 43%, respectively. Patients with AVR only had similar survival to patients who underwent concomitant AVR and CABG. Type of aortic prosthesis did not influence postoperative survival. CONCLUSIONS: In selected patients over the age of 80 with history of prior cardiac surgery, AVR can be performed safely with very good mid-term outcomes. Age alone should not be exclusion criteria for surgical AVR in octogenarians with prior cardiac surgery.

Five-year real world outcomes of GeoForm ring implantation in patients with ischemic mitral regurgitation.

BACKGROUND: Reductive ring annuloplasty represents the current standard surgical therapy for ischemic mitral regurgitation (IMR); however, the clinical results have been suboptimal. Etiology-specific prostheses such as the GeoForm annuloplasty ring have been designed to better address the annular and subvalvular perturbations associated with IMR. However, clinical experience is limited, and mid-term results are lacking. METHODS: We reviewed the clinical outcomes of 86 patients who had undergone implantation of a GeoForm ring at our center from 2005 to 2011. Perioperative mortality and clinical parameters were derived from The Society of Thoracic Surgeons database. Follow-up survival was assessed using the Social Security Death Index. Surviving patients were interviewed by telephone for valve-specific follow-up data and to complete the Medical Outcomes Study, short-form, 36-item, quality-of-life questionnaire. RESULTS: The mean grade of IMR preoperatively was 3.1±0.8 (range, 1-4+), 0.2±0.4 in the immediate postoperative period, and 0.7±0.7 at the last mean follow-up point of 41 months; only 2 patients developed ≥2+IMR during the follow-up period, for a 5-year freedom from recurrent 2+ IMR of 86%. The mean left ventricular end-diastolic and end-systolic diameters decreased from before to after surgery from 6.0±0.0 cm to 5.3±09 cm and 5.0±0.9 cm to 4.3±1.1 cm, respectively (P<.001). Perioperative mortality was 5.8% (5 of 86), and 1-, 3-, and 5-year survival was 87%, 81%, and 75%, respectively. At the last follow-up point, 80% of patients were in New York Heart Association class I and II, and their quality of life was equal to, or better than, age-matched controls from the general population. CONCLUSIONS: Implantation of the GeoForm ring offers very good control of IMR, with low rate of recurrent IMR at mid-term follow-up. The use of this prosthesis was associated with good perioperative mortality, mid-term survival, and quality of life.

Differences in clinical characteristics, management, and outcomes of intraoperative versus spontaneous acute type A aortic dissection.

BACKGROUND: The clinical characteristics, management, and outcomes of patients who had intraoperative aortic dissection (IAD) have not been thoroughly investigated. This study compared early and late clinical outcomes in patients with IAD vs spontaneous (non-IAD) acute type A aortic dissection. METHODS: Between January 1, 2000, and July 1, 2008, 251 patients from 4 academic medical centers underwent repair of acute type A aortic dissection; of those, 11 had IAD. The mean age was 72 ± 9 years for patients experiencing IAD and 59 ± 13 years for those with non-IAD (p = 0.001). Patients with IAD were more likely to have coronary artery disease (p = 0.003) and a history of arrhythmia (p = 0.038). Rates for major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. RESULTS: Operative mortality was not adversely influenced by IAD (27% IAD vs 17% non-IAD, p = 0.42). There were no differences in the rates of reoperation for bleeding (10% IAD vs 20% non-IAD, p = 0.69), stroke (18% IAD vs 18% non-IAD, p ≥ 0.99), or acute renal failure (9% IAD vs 22% non-IAD, p = 0.47) between the two groups. Actuarial 5-year survival was 64% for IAD patients vs 73% for non-IAD patients (p = 0.33). CONCLUSIONS: IAD does not adversely influence early outcomes and actuarial 5-year survival of patients with type A dissection.

Adrenal insufficiency in cardiothoracic patients: an evaluation of the corticotrophin stimulation test and other diagnostic methods.

PURPOSE: The purposes of the study were to determine the incidence of adrenal insufficiency (AI) using several published techniques, compare the response rates using a low-dose (LD) corticotropin (ACTH) stimulation test vs a standard dose (SD), and identify the technique that is most closely related to vasopressor use. MATERIALS AND METHODS: Consecutive adult patients who were undergoing open heart surgery for CAD or valvular disease were prospectively enrolled. Exclusion criteria included history of steroid use, operative steroid, or etomidate administration. Postoperatively, each patient underwent ACTH stimulation with 1 µg (LD) and 249 µg (SD), 60 minutes apart. Agreement among the tests was evaluated, and vasopressor use was compared between groups. RESULTS: There were 40 patients evaluated. The incidence of AI based on operative change, postoperative values, and LD-ACTH and SD-ACTH tests was 53%, 38%, 60%, and 38%, respectively. Agreement between the LD- and SD-ACTH tests was 73% (κ = 0.476, P = .001). There was a significant difference in the need for (93% vs 52%, P = .013) and duration (18.9 [0-180.6] vs 0.6 [0-73.2] hours, P = .003) of vasopressor therapy in patients with and without AI but only using the SD-ACTH definition. CONCLUSION: The incidence of AI will vary greatly based on technique used for diagnosis. The SD-ACTH stimulation test should be used to determine AI in open heart patients postoperatively because of the close association with vasopressor usage.