Risk factors and early outcomes of repeat sternotomy in 1960 adults with congenital heart disease: A 30-year, single-center study.

OBJECTIVE: Patients with congenital heart disease (CHD) increasingly live into adulthood, often requiring cardiac reoperation. We aimed to assess the outcomes of adults with CHD (ACHD) undergoing repeat sternotomy at our institution. METHODS: Review of our institution's cardiac surgery database identified 1960 ACHD patients undergoing repeat median sternotomy from 1993 to 2023. The primary outcome was early mortality, and the secondary outcome was a composite end point of mortality and significant morbidity. Univariable and multivariable logistic regression models were used to determine factors independently associated with outcomes. RESULTS: Of the 1960 ACHDs patient undergoing repeat sternotomy, 1183 (60.3%) underwent a second, third (n = 506, 25.8%), fourth (n = 168, 8.5%), fifth (n = 70, 3.5%), and sixth sternotomy or greater (n = 33, 1.6%). CHD diagnoses were minor complexity (n = 145, 7.4%), moderate complexity (n = 1380, 70.4%), and major complexity (n = 435, 22.1%). Distribution of procedures included valve (n = 549, 28%), congenital (n = 625, 32%), aortic (n = 104, 5.3%), and major procedural combinations (n = 682, 34.7%). Overall early mortality was 3.1%. Factors independently associated with early mortality were older age at surgery, CHD of major complexity, preoperative renal failure, preoperative ejection fraction, urgent operation, and postoperative blood transfusion. In addition, sternotomy number and bypass time were independently associated with the composite outcome. CONCLUSIONS: Despite the increase in early mortality with sternotomy number, sternotomy number was not independently associated with early mortality but with increased morbidity. Improvement strategies should target factors leading to urgent operations, early referral, along with operative efficiency including bypass time and blood conservation.

Impact of Hospital Volume on Outcomes of Septal Myectomy for Hypertrophic Cardiomyopathy.

BACKGROUND: Left ventricular outflow tract obstruction is common among symptomatic patients with hypertrophic cardiomyopathy, yet septal reduction by surgical myectomy (septal myectomy [SM]) is performed infrequently in many centers. This study examined the possible relationship between institutional case volume and early outcomes of SM. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for patients with hypertrophic cardiomyopathy who underwent SM from January 2012 to December 2019. The study defined center case volume categories as <1, 1 to 4.99, 5 to 9.99, and ≥10 cases performed on average per year. RESULTS: The study population included 5935 patients at 481 centers with 933 surgeons. The range of average center volume was <1 to 138 cases per year. Overall early mortality was 2.6%, ventricular septal defect (VSD) occurred in 1.9%, and complete heart block occurred in 9.0%. Concomitant mitral valve (MV) repair was performed in 28.7%, and MV replacement was performed in 17.1%. In multivariable analysis, the lowest annual case volume (average <1 case/y) was consistently associated with greater early mortality (odds ratio [OR], 5.4; CI, 3.0-9.9; P < .001), greater risk of VSD (OR, 9.3; CI ,4.2-20.4; P < .001), increased incidence of complete heart block (OR, 2.0; CI, 1.5-2.7; P < .001), and a higher likelihood of MV replacement (OR, 9.4; CI, 7.5-11.8; P < .001). CONCLUSIONS: Volume of SM cases varies widely among institutions reporting to the Society of Thoracic Surgeons Adult Cardiac Surgery Database. There appears to be an important association between surgical experience, as reflected by institutional case volume, and early outcomes, including mortality, as well as the occurrence of VSD, heart block, and MV replacement.

From Safety to Benefit in Cell Delivery During Surgical Repair of Ebstein Anomaly: Initial Results.

BACKGROUND: The objective of this study is to assess the safety and early impact of intramyocardial delivery of autologous bone marrow-derived mononuclear cells (BM-MNC) at time of surgical Ebstein repair. METHODS: Patients with Ebstein anomaly (ages 6 months to 30 years) scheduled to undergo repair of the tricuspid valve were eligible to participate in this open-label, non-randomized phase I clinical trial. BM-MNC target dose was 1-3 million cells/kg. Ten patients have undergone surgical intervention and cell delivery to the right ventricle (RV) and completed 6-month follow-up. RESULTS: All patients underwent surgical tricuspid valve repair and uneventful BM-MNC delivery; there were no ventricular arrhythmias and no adverse events related to study product or delivery. Echocardiographic RV myocardial performance index improved and RV fractional area change showed an initial decline and then through study follow-up. There was no evidence of delayed myocardial enhancement or regional wall motion abnormalities at injection sites on 6-month follow-up magnetic resonance imaging. CONCLUSIONS: Intramyocardial delivery of BM-MNC after surgical repair in Ebstein anomaly can be performed safely. Echocardiography variables suggest a positive impact of cell delivery on the RV myocardium with improvements in both RV size and wall motion over time. Additional follow-up and comparison to control groups are required to better characterize the impact of cell therapy on the myopathic RV in Ebstein anomaly.

Cone Reconstruction for Ebstein Anomaly: Ventricular Remodeling and Preliminary Impact of Stem Cell Therapy.

OBJECTIVE: To define the impact of tricuspid valve cone reconstruction (CR) on ventricular performance in Ebstein anomaly, both independently and after stem cell therapy. PATIENTS AND METHODS: The control group included 257 patients who had CR between June 2007 and December 2019. Ten subjects of a phase I stem cell therapy trial (May 2017 - March 2019) were compared with the controls to assess the echocardiographic impact on ventricular remodeling. RESULTS: After CR, right ventricular (RV) size decreased and left ventricular (LV) volume increased in all patients. Apical and biplane RV fractional area change (FAC) initially decreased, but rebounded by 6 months postoperation. Short-axis FAC increased early and was maintained at 6 months post-CR in the control group. At 6 months post-CR, cell therapy patients showed a significantly larger increase in short-axis FAC (24.4% vs 29.9%, P=.003). In addition, whereas LV ejection fraction (EF) was unchanged at 6 months post-CR in controls, cell therapy patients showed a significant increase in EF relative to baseline and to controls (55.6% vs 65.0%, P=.007). CONCLUSION: Cone reconstruction reduces tricuspid regurgitation and RV size, but is also associated with increased RV FAC and LV volume. Furthermore, injection of bone marrow-derived stem cells augmented the increase in RV FAC and was associated with improved LV EF at 6 months post-CR. This is evidence of a favorable interventricular interaction. These findings provide motivation for continued investigation into the potential benefits of stem cell therapy in Ebstein anomaly and other congenital cardiac malformations. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT02914171.

What Drives Opioid Prescriptions After Cardiac Surgery: Practice or Patient?

BACKGROUND: The objectives of this study were to describe opioid prescribing after hospitalization for elective cardiac operation, to identify factors associated with increased opioid prescriptions, and to develop procedure-specific opioid prescribing guidelines. METHODS: We analyzed data from all adults (≥18 years) undergoing elective cardiac operation for acquired heart disease from July 2014 to March 2017 at 3 affiliated hospitals. Opioid prescription data were abstracted and converted to morphine milligram equivalents (MME). Multivariable logistic regression was performed with the outcome of top-quartile prescriptions. RESULTS: There were 4145 study patients after exclusion of preoperative opioid users (10.5%). Mean ± SD patient age was 63.9 ± 13.2 years, and 68.4% (n = 2835) were male. The operation was the first in 87.3% (3617); the most common operative approach was sternotomy in 91.0% (n = 3773), followed by robot-assisted operation in 4.6% (n = 192). The majority of patients, 72.7%, received an opioid prescription at hospital dismissal, with a median opioid prescription of 200 MME (interquartile range 0 to 375 MME; range 0 to 6400 MME). This varied by hospital, with medians of 150, 450, and 600 MME (P < .001). On multivariable analysis, the factor with greatest association with top-quartile opioid prescription was hospital (odds ratio, 57.2, highest vs lowest; 95% confidence interval, 40.2-81.4; P < .001). CONCLUSIONS: Significant variation in opioid prescribing practices after cardiac operation was observed. The primary driver was hospital-centric as opposed to patient specific. Opioid prescribing guidelines were established to standardize posthospital pain management.

Postoperative Opioid Consumption in Thoracic Surgery Patients: How Much Is Actually Used?

BACKGROUND: The objective of this initiative was to perform a prospective, multicenter survey of patients after lung resection to assess the amount of opioid medication consumed and the disposition of unused opioids to inform the development of evidence-based prescribing guidelines. METHODS: Adults undergoing lung resection with either minimally invasive surgery (MIS; n = 108) or thoracotomy (n = 45) were identified prospectively from 3 academic centers (from March 2017 to January 2018) to complete a 28-question telephone survey 21 to 35 days after discharge. Discharge opioids were converted into morphine milligram equivalents (MME) and were compared across patient and surgical details. RESULTS: Of the 153 patients who completed the survey, 89.5% (137) received opioids at discharge with a median prescription of 320 MME (interquartile range [IQR], 225, 450 MME) after MIS and 450 MME (IQR, 300, 600 MME) after thoracotomy (P = .001). Median opioid consumption varied by surgical approach: 90 MME (IQR, 0, 262.5) after MIS and 300 MME (IQR, 50, 382.5 MME) after thoracotomy (P < .001). The majority of patients (73.7%; 101) had residual opioid medication at the time of the survey, and patients after MIS had a relative increase in amount of remaining opioid medication: 58.3% vs 33.3% (P = .05) of the original prescription. Only 5.9% of patients with opioids remaining had properly disposed of them. CONCLUSIONS: Although patients undergoing MIS lung resection used significantly less opioid medication over a shorter duration of time than did patients after thoracotomy, they had relatively more excess opioid prescription. Evidence-based, procedure-specific guidelines with tailored pain regimens should be developed and implemented to reduce the amount of postoperative opioid medication remaining in the community.

Septal Myectomy in Hypertrophic Cardiomyopathy: National Outcomes of Concomitant Mitral Surgery.

OBJECTIVES: To assess the frequency and implications of mitral valve (MV) surgery at the time of septal myectomy (SM) for hypertrophic cardiomyopathy (HCM) in a national cohort. PATIENTS AND METHODS: The National Inpatient Sample (NIS) was used to analyze surgical outcomes in patients with HCM undergoing SM from January 1, 2003, through December 31, 2014. Univariate analyses were used to compare patients undergoing SM with vs without concomitant procedures, and logistic regression was used to determine factors associated with prolonged length of stay (LOS) and in-hospital mortality. Numeric values of 10 or less were not reported per NIS data use agreements. RESULTS: The national cohort included 1174 adults with a primary diagnosis of HCM undergoing SM. Overall mean ± SD age was 54.4±14.5 years, and 45% of patients (n=529) were male. Isolated SM was performed in 67% (n=786), and the remainder had concomitant cardiac procedures, most frequently MV repair/replacement (22%, n=257). Median LOS was increased in those with concomitant MV surgery, 7 days, compared with isolated SM, 6 days (P<.001). Overall hospital mortality was 2.9% (n=34) and was lowest in those undergoing isolated SM (<1%; P<.001). In otherwise isolated SM, MV replacement increased likelihood of in-hospital death (odds ratio, 12.0; 95% CI, 3.9-36.5; P<.001) on a univariate basis. CONCLUSION: Intervention on the MV is more common nationally than in specialized centers, and the addition of MV replacement and other concomitant cardiac procedures was associated with increased rates of hospital mortality and LOS compared with patients undergoing isolated SM. These results suggest that concomitant MV intervention is associated with increased risk.

Surgical Management and Outcomes of Ebstein Anomaly in Neonates and Infants: A Society of Thoracic Surgeons Congenital Heart Surgery Database Analysis.

BACKGROUND: Ebstein anomaly (EA) encompasses a broad spectrum of morphology and clinical presentation. Those who are symptomatic early in infancy are generally at highest risk, but there are limited data regarding multicentric practice patterns and outcomes. We analyzed multiinstitutional data concerning operations and outcomes in neonates and infants with EA. METHODS: Index operations reported in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 to 2016) were potentially eligible for inclusion. Analysis was limited to patients with diagnosis of EA and less than 1 year of age at time of surgery (neonates ≤30 days, infants 31 to 365 days). RESULTS: The study population included 255 neonates and 239 infants (at 95 centers). Among neonates, median age at operation was 7 days (interquartile range, 4 to 13 days) and the majority required preoperative ventilation (61.6%, n = 157). The most common primary operation performed among neonates was Ebstein repair (39.6%, n = 101), followed by systemic-to-pulmonary shunt (20.4%, n = 52) and tricuspid valve closure (9.4%, n = 24). Overall neonatal operative mortality was 27.4% (n = 70), with composite morbidity-mortality of 51.4% (n = 48). For infants, median age at operation was 179 days (interquartile range, 108-234 days); the most common primary operation for infants was superior cavopulmonary anastomosis (38.1%, n = 91) followed by Ebstein repair (15.5%, n = 37). Overall operative mortality for infants was 9.2% (n = 22) with composite morbidity-mortality of 20.1% (48). CONCLUSIONS: Symptomatic EA in early infancy is very high risk and a variety of operative procedures were performed. A dedicated prospective study is required to more fully understand optimal selection of treatment pathways to guide a systematic approach to operative management.

Improving Results of Surgery for Ebstein Anomaly: Where Are We After 235 Cone Repairs?

BACKGROUND: Ebstein anomaly has heterogeneous anatomy and numerous operative techniques are described. Cone repair provides a near anatomic tricuspid valve repair. The purpose of this study was to examine our experience with cone repair. METHODS: Cone repair was performed in 235 consecutive patients with Ebstein anomaly, 134 children (57%) and 101 adults (43%), from June 2007 to October 2015. Median age was 15.6 years (range, 6 months to 73 years). Cone repair was the first operation in 192 patients (82%), the second in 41 (17%), and the third in 2 (1%). Previous tricuspid valve repair had been performed in 27 (12%). Echocardiograms were obtained preoperatively and at hospital dismissal for all patients and for a subgroup of patients at least 6 months after cone repair (n = 81). RESULTS: Leaflet augmentation was done in 67 patients (28%), Sebening stitch in 57 (24.2%), neochordae in 49 (21%), and annuloplasty band in 158 (67%). Bidirectional cavopulmonary shunt was performed in 46 patients (20%). There was 1 early death (0.4%). Early reoperation was required in 14 patients (5.9%); re-repair was possible in 7 (50%). The majority of early reoperations (11 of 14; 79%) occurred in the first third of the series. Mean follow-up was 3.5 ± 2.5 years. There was sustained reduction in tricuspid regurgitation (p < 0.0001), a progressive decline in right ventricle size (p < 0.0001), and late increase in right ventricle fractional area change after initial decline (p < 0.0001). Freedom from late reoperation was 97.9% at 6 years. CONCLUSIONS: Cone repair is safe, and the learning curve is significant. Sustained reduction in tricuspid regurgitation and favorable changes in the right ventricle at follow-up suggest that cone repair has an advantageous impact on right ventricular remodeling.