Severe Mitral Paravalvular Leak Treated with Percutaneous Paravalvular Leak Closure with Underlying Severe Mitral Annular Calcium.

Standard operative mitral valve replacement for mitral stenosis in the setting of severe mitral annular calcium has been associated with increased morbidity and mortality. Inability to ensure a well seated prosthesis may lead to periprosthetic leak. We present a case of severe paravalvular leak, causing significant hemolysis, after mitral valve replacement with underling severe mitral annular calcium. The leak was successfully repaired using a transseptal percutaneous approach, with subsequent resolution of hemolysis.

Long-term outcomes of patients with primary graft dysfunction after cardiac transplantation.

OBJECTIVES: The International Society of Heart and Lung Transplantation (ISHLT) criteria for primary graft dysfunction (PGD) after cardiac transplantation have been shown to stratify patient outcomes up to 1 year after transplantation, but scarce data are available regarding outcomes beyond the 1st year. We sought to characterize survival of patients with PGD following cardiac transplantation beyond the 1st year. METHODS: A retrospective review of consecutive patients undergoing isolated cardiac transplantation at a single centre between 2012 and 2015 was performed. Patients were diagnosed with none, mild, moderate or severe PGD by the ISHLT criteria. Survival was ascertained from the United Network for Organ Sharing database and chart review. Kaplan-Meier curves were plotted to compare survival. The hazard ratio for mortality associated with PGD severity was estimated using Cox-proportional hazards modelling, with a pre-specified conditional survival analysis at 90 days. RESULTS: A total of 257 consecutive patients underwent cardiac transplantation during the study period, of whom 73 (28%) met ISHLT criteria for PGD: 43 (17%) mild, 12 (5%) moderate and 18 (7%) severe. Patients with moderate or severe PGD had decreased survival up to 5 years after transplantation (log-rank P < 0.001). Landmark analyses demonstrated that patients with moderate or severe PGD were at increased risk of mortality during the first 90-days after transplantation as compared to those with none or mild PGD [hazard ratio (95% confidence interval) 18.9 (7.1-50.5); P < 0.001], but this hazard did not persist beyond 90-days in survivors (P = 0.64). CONCLUSIONS: A diagnosis of moderate or severe PGD is associated with increased mortality up to 5 years after cardiac transplantation. However, patients with moderate or severe PGD who survive to post-transplantation day 90 are no longer at increased risk for mortality as compared to those with none or mild PGD.

High-quality cardiac surgery through teamwork.

The high-quality cardiothoracic surgery program is primed for mindful effective surgery. The challenge lies in attaining mindful skills and efficiency. Herein is one journey toward high departmental quality over two decades.

Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation.

OBJECTIVES: Prior sternotomy is associated with increased morbidity and mortality following heart transplantation. However, its effect on primary graft dysfunction (PGD), a major contributor to early mortality, is unknown. Herein, this effect is studied using the International Society for Heart and Lung Transplantation consensus definition for PGD. METHODS: Medical records of consecutive adult cardiac transplants between 2012 and 2016 were reviewed. Baseline characteristics, postoperative findings and 1-year survival were compared between patients with and without prior sternotomy. RESULTS: Among 255 total patients included, 139 (55%) had undergone prior sternotomy; these recipients were older, more often male, had higher body mass index, higher frequencies of united network for organ sharing (UNOS) 1A status and ischaemic cardiomyopathy and experienced longer waitlist times when compared with those without prior sternotomy (all P < 0.018). Postoperatively, the prior sternotomy group exhibited higher rates of mild to severe PGD (32% vs 18%; P = 0.015) and higher short-term mortality (P = 0.017) and 1-year mortality (P = 0.047). They required more blood transfusions, had more postoperative pneumonia, wound infection and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of PGD (odds ratio 2.7). Multiple prior sternotomies was associated with even more UNOS 1A status, ischaemic cardiomyopathy and pneumonia. However, logistic modelling did not show a difference in the rate of PGD between those with 1 or ≥2 prior sternotomies. CONCLUSIONS: Our data suggest that prior sternotomy is a risk factor for PGD. Consistent with previous reports, prior sternotomy is associated with increased morbidity, blood product utilization and 1-year mortality following cardiac transplantation.

Application of the International Society for Heart and Lung Transplantation (ISHLT) criteria for primary graft dysfunction after cardiac transplantation: outcomes from a high-volume centre†.

OBJECTIVES: A standardized definition for primary graft dysfunction (PGD) after cardiac transplantation was recently proposed by the International Society of Heart and Lung Transplantation (ISHLT). We sought to characterize the outcomes associated with and identify risk factors for PGD following cardiac transplantation using these criteria at a high volume centre. METHODS: Donor and recipient medical records of 201 consecutive adult cardiac transplantations performed between November 2012 and March 2015 were retrospectively reviewed. Patients undergoing isolated heart transplantation were diagnosed with none, mild, moderate, or severe PGD using ISHLT criteria. Cumulative survival was calculated according to the Kaplan­Meier method. Associations of risk factors for combined moderate/severe PGD were assessed with univariate and multivariate analyses. RESULTS: A total of 191 consecutive patients underwent isolated heart transplantation, and 59 (30%) met ISHLT criteria for PGD: 35 (18%) mild, 8 (4%) moderate and 16 (8%) severe. Thirty-day/in-hospital mortality occurred in six (3%) patients, all of whom were diagnosed with severe PGD. Patients with moderate/severe PGD also had significantly increased intensive care unit length of stay (LOS), total LOS, reoperations for bleeding and postoperative infections. Survival at 1-year was diminished with increasing severity of PGD (none 93%, mild 94%, moderate 75% and severe 44%; log-rank P < 0.001). Elevated preoperative creatinine, pretransplantation hospitalized recipient and undersized donor were independently predictive of moderate/severe PGD. CONCLUSIONS: A diagnosis of PGD portends worse outcomes including increased 30-day and 1-year mortality. The ISHLT diagnostic criteria for moderate and severe PGD identify and discriminate patients with PGD in a clinically relevant manner.

Distal aortic interventions after repair of ascending dissection: the argument for a more aggressive approach.

OBJECTIVE: Survivors of ascending aortic dissection repair frequently require downstream aortic interventions. Because of a paucity of data, we assessed early and long-term outcomes, and risk factors, of these distal procedures. METHODS: From January 1993 to January 2011, 305 patients underwent 429 distal aortic interventions after acute type A (95% DeBakey type I) dissection repair performed 3.8 years earlier (median); 11% of interventions used an endovascular approach. Maximum aortic size was 5.9 ± 1.3 cm. Median follow-up was 3.6 years. RESULTS: Hospital mortality was 6.1%. Risk factors included graft infection, concomitant coronary artery bypass grafting, combined open arch and descending procedures, and lower distal anastomotic site. Within 10 years, the probability of patients undergoing a reintervention was 38%, with a cumulative incidence of 55 per 100 patients; however, 40 (9.3%) were stage-II elephant trunks. Patients with larger aortic diameters distal to the initial repair, and a stage-I elephant trunk, were more likely to undergo distal interventions. Survival was 65% at 10 years. Higher body mass index, a longer time between reinterventions, graft infection, combined open arch and descending procedures, and lower distal anastomosis sites were risk factors. The extent of aorta replaced was not associated with increased morbidity or mortality, unless it involved a combined open arch and descending aorta procedure. CONCLUSIONS: Distal interventions after ascending aortic dissection repair are feasible, but they are associated with early morbidity and subsequent reinterventions. Rigorous follow-up with early reintervention is important for improving short- and long-term outcomes. An extended hybrid endovascular repair for initial dissection warrants study.

Modifications, classification, and outcomes of elephant-trunk procedures.

BACKGROUND: There are a variety of modified elephant-trunk methods, including use of endovascular stents. Our objectives were to classify these modifications, compare outcomes between the classic anastomotic site and these alternatives, and investigate time to second-stage elephant-trunk completion. METHODS: From May 1992 to January 2011, 526 patients underwent a first-stage elephant-trunk procedure and were the subject of analysis. RESULTS: Distal aortic anastomosis was located before the brachiocephalic artery in 6 patients (1.1%), between brachiocephalic and left common carotid artery (LCCA) in 1 (0.19%), between LCCA and left subclavian artery (LSCA) in 154 (29%), and beyond the LSCA (classic) in 365 (69%). Stroke occurred in 8% (n = 42) overall, 10% (n = 16) in the LCCA-LSCA group, and 6.8% (n = 25) in the classic group. Risk factors were older age and acute dissection. Thirty-day mortality was 7.6% (n = 40) and was similar for LCCA-LSCA (9.7%) and classic sites (6.3%; p = 0.7); risk factors included older age, smaller body surface area, and end-organ dysfunction. Likelihood of death before second-stage elephant trunk at 1, 4, and 8 years after operation was 16%, 22%, and 27%, respectively. The larger the distal aorta, the more likely was second-stage completion (p < 0.0001); when greater than 6 cm, 80% had second-stage completion. CONCLUSIONS: The elephant-trunk operation is safe for a broad population, including when anastomotic sites are other than beyond the LSCA. Without second-stage completion, patient mortality increases markedly after 4 years.