Optimizing Surgical Selection for Transposition With Left Ventricular Outflow Tract Obstruction.

BACKGROUND: Studies that have assessed the Rastelli and Nikaidoh operations for transposition of the great arteries (TGA) with obstructed left ventricular outflow tract obstruction (LVOTO) have not fully evaluated the anatomic drivers that may contribute to surgical selection. We present our procedural selection process for optimizing outcomes of complex TGA in the modern era. METHODS: This is a single-center, retrospective study that included pediatric patients who underwent either a Nikaidoh or Rastelli operation for the treatment of TGA-LVOTO, congenitally corrected TGA-LVOTO, or double-outlet right ventricle TGA type-LVOTO from June 2004 to June 2021. RESULTS: There were 34 patients stratified by Nikaidoh (n = 16) or Rastelli (n = 18) operation. The incidence of all postoperative complications and mortality was low, and the incidence of complications between the groups was similar. Patients were more likely to have undergone a Nikaidoh than a Rastelli if they had a pulmonary annulus >5 mm (87.5% vs 11.1%), anteriorly/posteriorly oriented great vessels (88% vs 8%), remote (80% vs 11%) or restrictive (75% vs 6%) ventricular septal defect, and right ventricular hypoplasia (50% vs 0%; all, P < .05). The resulting rates of reoperation were similar between the groups (44.0% vs 37.5%; P = .24) and largely composed of conduit replacements in the Rastelli patients and valvular repairs or replacements in the Nikaidoh group. Rates of catheter-based interventions were also similar. CONCLUSIONS: These findings suggest that for the optimal treatment of conotruncal anomalies with discordant ventriculoarterial connections, procedural selection should be based on pathoanatomic criteria that can ensure patients undergo the operation most suited to their anatomy.

Double outlet right ventricle.

This review article addresses the history, morphology, anatomy, medical management, and different surgical options for patients with double outlet right ventricle.

Optimal circulatory arrest temperature for aortic hemiarch replacement with antegrade brain perfusion.

OBJECTIVE: This study sought to identify the optimal temperature for moderate hypothermic circulatory arrest in patients undergoing elective hemiarch replacement with antegrade brain perfusion. METHODS: The Society of Thoracic Surgeons adult cardiac surgery database was queried for elective hemiarch replacements using antegrade brain perfusion for aneurysmal disease (2014-2019). Generalized estimating equations and restricted cubic splines were used to determine the risk-adjusted relationships between temperature as a continuous variable and outcomes. RESULTS: Elective hemiarch replacement with antegrade brain perfusion occurred in 3898 patients at 374 centers with a median nadir temperature of 24.9°C (first quartile, third quartile = 22.0°C, 27.5°C) and median circulatory arrest time of 19 minutes (first quartile, third quartile = 14.0 minutes, 27.0 minutes). After adjustment for comorbidities, circulatory arrest time, and individual surgeon, patients cooled between 25 and 28°C had an early survival advantage compared with 24°C, whereas those cooled between 21 and 23°C had higher risks of mortality compared with 24°C. A nadir temperature of 27°C was associated with the lowest risk-adjusted odds of mortality (odds ratio, 0.62; 95% confidence interval, 0.42-0.91). A nadir temperature of 21°C had the highest risk of mortality (odds ratio, 1.4; 95% confidence interval, 1.13-1.73). Risk of experiencing a major morbidity was elevated in patients cooled between 21 and 23°C, with the highest risk occurring in patients cooled to 21°C (odds ratio, 1.12; 95% confidence interval, 1.01-1.24). CONCLUSIONS: For patients with aneurysmal disease undergoing elective hemiarch with antegrade brain perfusion, circulatory arrest with a nadir temperature of 27°C confers the greatest early survival benefit and smallest risk of postoperative morbidity.

Evolution of extracorporeal membrane oxygenation trigger criteria in COVID-19 acute respiratory distress syndrome.

OBJECTIVE: To understand the implications of a tiered extracorporeal membrane oxygenation (ECMO) criteria framework and the outcomes of patients with COVID-19 acute respiratory distress syndrome who we were consulted on for ECMO but ultimately declined. METHODS: All patients declined for ECMO support by a large regional health care system between March 2020 and July 2021 were included. Restrictive selection criteria were enacted midway through the study stratifying the cohort into 2 groups. Primary outcomes included 30-day mortality. Secondary outcomes included reasons for declining ECMO and survival stratified by phase. RESULTS: One hundred ninety-three patients with COVID-19 acute respiratory distress syndrome were declined for ECMO within the study period out of 260 ECMO consults. At the time of consult, 71.0% (n = 137) were mechanically ventilated and 38% (n = 74) were proned and chemically paralyzed. Thirty-day mortality was 66% (n = 117), which increased from 53% to 73% (P = .010) when restrictive criteria were enacted. Patients with multisystem organ failure, prolonged ventilator time, and advanced age had respectively an 11-fold (odds ratio, 10.6; 95% CI, 1.7-65.2), 4-fold (odds ratio, 3.5; 95% CI, 1.1-12.0), and 4-fold (odds ratio, 4.4; 95% CI, 1.9-10.2) increase in the odds of mortality. CONCLUSIONS: Patients with COVID-19 acute respiratory distress syndrome declined for ECMO represent a critically ill cohort. We observed an increase in the severity of disease and 30-day mortality in consults in the latter phase of our study period. These findings may reflect our use of tiered selection criteria coupled with ongoing education and communication with referring centers, sparing both patients likely to respond to medical therapy and those who were unsalvageable by ECMO.

Midterm Outcomes of Isolated Coronary Artery Bypass Grafting in the Setting of Moderate Ischemic Mitral Regurgitation.

INTRODUCTION: Although randomized trial data exist for 2-y outcomes comparing isolated coronary artery bypass grafting (CABG) versus CABG with concomitant mitral valve repair (CABG + MVr) for the treatment of moderate ischemic mitral regurgitation (IMR), longer term outcomes are unclear. This study evaluated the longitudinal outcomes of isolated CABG for moderate IMR. METHODS: Patients with moderate IMR undergoing isolated CABG from January 2010 to February 2018 at a single institution were included. Outcomes included longitudinal freedom from heart failure readmission, survival, rates of persistent mitral regurgitation (MR), and freedom from mitral valve reinterventions. A subanalysis was conducted comparing CABG versus CABG + MVr. Multivariable Cox regression was used for risk adjustment. RESULTS: A total of 528 patients with moderate IMR underwent isolated CABG. Postoperatively, 26% of patients had at least moderate MR at 1-mo follow-up, although at 5 y progression to severe MR was rare (2.2%) as were mitral valve reinterventions (0.2%). Survival at 30 d (95.8%), 1 y (89.6%), and 5 y (76.6%) was acceptable. Furthermore, the freedom from readmission for heart failure was also acceptable at 30 d (92.6%), 1 y (79.9%), and 5 y (65.0%) postoperatively. In a subanalysis comparing CABG versus CABG + MVr, unadjusted and risk-adjusted survival, freedom from heart failure readmissions, mitral valve reinterventions, and degrees of MR were comparable between the groups at all intervals (all P > 0.05). CONCLUSIONS: The majority of patients with moderate IMR can undergo isolated CABG with acceptable rates of heart failure readmissions, survival, progression to severe MR, and the need for subsequent mitral interventions. These data support the use of isolated CABG in patients with moderate IMR.

Fate of the Kidneys in Patients with Post-Operative Renal Failure After Cardiac Surgery.

BACKGROUND: This study evaluates the clinical and renal-related outcomes in patients with acute renal failure (ARF) following cardiac surgery. METHODS: Index adult cardiac operations at a single institution from 2010-2018 were reviewed. Patients requiring dialysis pre-operatively were excluded. ARF was stratified as either creatinine rise (≥3-times baseline or ≥4.0 mg/dL) or post-operative dialysis. Outcomes included mortality, rates of progression to dialysis, and renal recovery. Multivariable Cox regression was used for risk-adjustment. RESULTS: A total of 10,037 patients, including 6,275 (62.5%) isolated coronary artery bypass grafting (CABG), 2,243 (22.3%) isolated valve, and 1,519 (15.1%) CABG plus valve cases, were included. Post-operative ARF occurred in 346 (3.5%) patients, with 230 (66.5%) requiring dialysis. Survival was significantly reduced in patients with ARF at 30-days (97.9 versus 70.8%, P <0.001), 1-year (94.9 versus 48.0%, P <0.001), and 5-years (86.2 versus 38.2%, P <0.001) with more profound reductions in those requiring dialysis, findings which persisted after risk-adjustment. Progression to subsequent dialysis in the creatinine rise group was rare (n = 1). The median time to dialysis initiation in the dialysis group was 5 days (IQR 2-12 days) with a median time of dialysis dependence of 72 days (IQR 38-1229 days). Of those patients requiring postoperative dialysis, 30.9% demonstrated renal recovery. CONCLUSIONS: Post-operative ARF and in particular the need for dialysis are associated with substantial reductions in survival that persist during longitudinal follow-up. This occurs despite the finding that patients experiencing creatinine rise only rarely progress to dialysis, and that nearly one-third of patients requiring post-operative dialysis recover renal function.

Implementation of a protocol to increase the academic productivity of cardiothoracic surgery resident physicians.

OBJECTIVE: Academic productivity during cardiothoracic surgery residency training is an important program metric, but is highly variable due to multiple factors. This study evaluated the influence of implementing a protocol to increase resident physicians' academic productivity in cardiac surgery. METHODS: A comprehensive protocol for cardiac surgery was implemented at our institution that included active pairing of residents with academically productive faculty, regular research meetings, centralized data storage and analysis with a core team of biostatisticians, a formal peer-review protocol for analytic requests, and project prioritization and feedback. We compared cardiothoracic surgery residents' academic productivity before implementation (July 2015-June 2017) versus after implementation (July 2017-June 2019). Academic productivity was measured by peer-reviewed articles, abstract presentations (oral or poster) at national cardiothoracic surgery meetings, and textbook chapters. RESULTS: Thirty-four resident physicians (from traditional and integrated programs) trained at our institution during the study. A total of 122 peer-reviewed articles were produced over the course of the study: 74 (60.7%) cardiac- and 48 (39.3%) thoracic-focused. The number of cardiac-focused resident-produced articles increased from 10 preimplementation to 64 postimplementation (0.61 vs 2.03 articles per resident; P < .01). Abstract oral or poster presentations also increased, from 11 to 40 (0.61 vs 1.33 abstracts per resident; P = .01). Textbook chapters increased from 4 to 15 following the intervention (0.22 vs 0.5 chapters per resident; P = .01). CONCLUSIONS: Implementation of a dedicated protocol to facilitate faculty mentoring of resident research and streamline the data access, analysis, and publication process substantially improved cardiothoracic surgery residents' academic productivity.

Aortic Root Replacement With Autologous Pericardium Valved Conduit.

Available aortic prosthesis replacement options present a challenge to achieving low perioperative morbidity, low pressure gradients, and prolonged durability. Trileaflet aortic valve reconstruction using autologous pericardium offers an alternative treatment option with excellent postoperative gradients, large effective orifice areas, and the avoidance of long-term anticoagulation. The modified Bentall procedure with either tissue xenograft valved conduit or mechanical valved conduit is considered the gold standard for patients with aortic root pathology requiring surgical replacement. We report a novel adaptation of the modified Bentall procedure with a self-fabricated valved conduit with trileaflet aortic valve neocuspidization using autologous pericardium.

Utilization and Outcomes of the Nikaidoh, Rastelli, and REV Procedures: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database.

BACKGROUND: Aortic root translocation (Nikaidoh), Rastelli, and réparation à l'etage ventriculaire (REV) are repair options for transposition of the great arteries (TGA) with ventricular septal defects and left ventricular outflow tract obstruction (VSD-LVOTO) or double outlet right ventricle TGA type (DORV-TGA). METHODS: This retrospective study using The Society of Thoracic Surgeons Congenital Heart Surgery Database evaluates surgical procedure utilization and outcomes of patients undergoing repair of TGA-VSD-LVOTO and DORV-TGA with a Nikaidoh, Rastelli, or REV procedure. RESULTS: A total of 293 patients underwent repair at 82 centers (January 2010 to June 2019). Most patients underwent a Rastelli (n = 165, 56.3%) or a Nikaidoh (n = 119, 40.6%) operation; only 3.1% (n = 9) underwent a REV. High-volume centers performed the majority of the repairs. Fewer Nikaidoh than Rastelli patients had prior cardiac operations (n = 57 [48.7%] vs n = 102 [63.0%]; P = .004). Nikaidohs had longer median cardiopulmonary bypass time (227 [interquartile range (IQR), 167-299] minutes vs 175 [IQR, 133-225] minutes; P < .001) and median aortic cross-clamp times (131 [IQR, 91-175] minutes vs 105 [IQR, 82-141] minutes; P = .0015). Operative mortality was 3.1% (95% confidence interval [CI], 1.0%-7.0%; n = 5) for Rastelli, 4.4% (95% CI, 1.4%-9.9%; n = 5) for Nikaidoh, and 11.1% (95% CI, 0.3%-48.3%, n = 1) for REV. The rates of cardiac arrest, unplanned reoperation, mechanical circulatory support, prolonged ventilation, and permanent pacemaker placement were higher in the Nikaidoh population but with 95% CIs overlapping those of the other procedures. CONCLUSIONS: Rastelli and Nikaidoh procedures are the prevalent repair strategies for patients with DORV-TGA and TGA-VSD-LVOTO. Most are performed at high-volume institutions, and early outcomes are similar.

Recent Changes in Durable Left Ventricular Assist Device Bridging to Heart Transplantation.

This study evaluates the impact of the recent United Network for Organ Sharing (UNOS) allocation policy change on outcomes of patients bridged with durable left ventricular assist devices (LVADs) to orthotopic heart transplantation (OHT). Adults bridged to OHT with durable LVADs between 2010 and 2019 were included. Patients were stratified based on the temporal relationship of their OHT to the UNOS policy change on October 18, 2018. The primary outcome was early post-OHT survival. In total, 9,628 OHTs were bridged with durable LVADs, including 701 (7.3%) under the new policy. Of all OHTs performed during the study period, the proportion occurring following durable LVAD bridging decreased from 45% to 34% (p < 0.001). The more recent cohort was higher risk, including more extracorporeal membrane oxygenation bridging (2.6% vs. 0.3%, p < 0.001), more mechanical right ventricular support (9.7% vs. 1.4%, p < 0.001), greater pretransplant ICU admission (22.8% vs. 8.7%, p < 0.001) more need for total functional assistance (62.8% vs. 53.0%, p < 0.001), older donor age (33.3 vs. 31.7 years, p < 0.001), and longer ischemic times (3.38 vs. 3.13 hours, p < 0.001). Despite this, early post-OHT survival was comparable at 30 days (96.1% vs. 96.0%, p = 0.89), 90 days (93.7% vs. 94.0%, p = 0.76), and 6 months (91.0% vs. 93.0%, p = 0.96), findings that persisted after risk-adjustment. In this early analysis, OHT following bridging with durable LVADs is performed less frequently and in higher risk recipients under the new allocation policy. Despite this, short-term posttransplant outcomes appear to be unaffected in this patient cohort in the current era.

Impact of the 2018 change in US allocation policy on adults with congenital heart disease.

BACKGROUND: The US adult heart allocation policy was changed on October 18, 2018. This study aims to evaluate its impact on orthotopic heart transplantation (OHT) for adults with congenital heart disease (ACHD). METHODS: The United Network for Organ Sharing database was used to perform 2 comparisons: waitlist outcomes among listed ACHD candidates, and post-transplant outcomes in those transplanted. Waitlisted candidates were stratified by date of waitlisting: Period 1: 2010 to 2013; Period 2: 2014 to October 17, 2018 and Period 3: October 18, 2018 to March 20, 2020. Transplanted ACHD patients were similarly stratified but by date of transplantation. Competing risk regression for waitlist outcomes was performed. Post-transplant survival was analyzed using the Kaplan-Meier method and multivariable Cox regression. RESULTS: Nine hundred and seventy-six patients with ACHD were waitlisted for OHT in our study: 343(35.1%), 466(47.8%), and 167(17.1%) in periods 1, 2, and 3. Post-policy change, 1-year cumulative incidence of waitlist mortality or deterioration decreased (p = 0.02). Six hundred and forty-eight patients were transplanted: 221(34.1%), 329(50.8%) and 98(15.1%) respectively. In those transplanted, post-policy median waitlist time (174, 161 and 38 days, p < 0.001) decreased and the use of intra-aortic balloon pumps increased (1.4%, 4.9% and 19.4%, p < 0.001). Compared to periods 1 and 2, risk-adjusted post-transplant 1-year mortality was similar to period 3 (HR 1.10, 95% CI 0.52-2.32; p = 0.81) (HR 1.19, 95% CI 0.58-2.46, p = 0.63). CONCLUSIONS: The recent US allocation policy change may have resulted in reduced waitlist times and 1-year waitlist mortality for OHTs in ACHD patients. Early post-transplant outcomes appear comparable post-policy change.

Operative mortality in adult cardiac surgery: is the currently utilized definition justified?

BACKGROUND: This study evaluated operative mortalities following adult cardiac surgical operations to determine if this metric remains appropriate for the modern era. METHODS: This was a retrospective review of Society of Thoracic Surgeons (STS) indexed adult cardiac operations that included coronary artery bypass grafting (CABG), aortic valve replacement (AVR), CABG + AVR, mitral valve repair (MVr), CABG + MVr, mitral valve replacement (MVR) and CABG + MVR, performed at a single institution between 2011 and 2017. The primary outcome was the timing and relatedness of operation mortality, as defined by the STS as mortality within 30-day or during the index hospitalization, compared to the index operation. The secondary outcomes evaluated cause of death and the rates of postoperative complications. RESULTS: A total of 11,190 index cardiac operations were performed during the study period and operative mortality occurred in 246 (2.2%) of patients. The distribution of operative mortalities included 83.7% (n=206) who expired within 30-day while an inpatient, 6.9% (n=17) died within 30-day as an outpatient, 11.2% (n=23) expired after 30-day. The most common causes of operative mortality were cardiac (38.7%, n=92), renal failure (15.6%, n=37), and strokes (13.9%, n=33). Furthermore, 98.4% (n=242) of deaths were attributable to the index operation. Postoperative complications occurred frequently in those with operative mortality, with blood transfusions (80.1%), reoperations (65.0%) and prolonged ventilation (62.2%) being most common. CONCLUSIONS: Most of the operative mortalities seemed to be attributable to the index cardiac operation. We believe that the current definition of mortality remains appropriate in the modern era.

Pre-implant left ventricular dimension is not associated with worse outcomes after left ventricular assist device implantation.

BACKGROUND: Left ventricular dimension has the potential to impact clinical outcomes following implantation of left ventricular assist devices (LVAD). We investigated the effect of pre-implant left ventricular end-diastolic diameter (LVEDD) on outcomes following LVAD implantation. METHODS: Patients implanted with a continuous-flow LVAD between 2004 and 2018 at a single institution were included. The primary outcome was death while on LVAD support. Secondary outcomes included adverse event rates such as renal failure requiring dialysis, device thrombosis, and right ventricular failure. The LVEDD measurements were dichotomized using restricted cubic splines and threshold regression. Survival was determined using Kaplan-Meier estimates. Multivariable logistic regression was used to determine risk-adjusted mortality based on LVEDD. RESULTS: A total of 344 patients underwent implantation of a continuous flow LVAD during the study period. The optimal cut point for LVEDD was 65 mm, with 126 (36.6%) subjects in the <65 mm group and 165 (48.0%) in the >65 mm group. The LVEDD <65 mm group was older, had more females, higher incidence of diabetes, more pre-implant mechanical ventilation, and more admissions for acute myocardial infarctions (all, P<0.05). Importantly, post-implant adverse events were similar between the groups (all, P>0.05). Risk-adjusted survival at 1-year (OR 1.3, 95% CI: 0.6-2.5, P=0.53) was also comparable between the groups. Furthermore, incremental increases in LVEDD when modeled as a continuous variable did not impact overall mortality (OR 0.98, 95% CI: 0.9-1.0, P=0.09). CONCLUSIONS: Preoperative LVEDD was not associated with rates of major morbidities or mortality following LVAD implantation.