Efficacy of nasal continuous positive airway pressure as a preferred airway management during intravenous sedation of patients undergoing transcatheter aortic valve replacement.

Background: As the incidence of aortic stenosis is increasing in correlation with the aging population, symptomatic patients commonly require valve replacement procedures. If left untreated, symptomatic aortic stenosis can lead to death in 2 to 3 years. Often, transcatheter aortic valve replacement (TAVR) procedures are performed with the assistance of oxygenation via nasal cannula. However, oxygenation achieved through a nasal continuous positive airway pressure (nCPAP) device could be a more optimized strategy for patients without any sacrifice in efficacy compared to nasal cannula. Methods: A retrospective chart review was conducted on 28 patients at Baylor University Medical Center who presented to the operating room for a TAVR between January and October 2021. Fourteen patients received oxygenation via nasal cannula (control group) and 14 received oxygenation with nCPAP. Information gathered included method of oxygenation, length of stay, episodes of hypoxia (defined as sustained oxygen saturation <92% for at least 1 minute), paravalvular leak, pacemaker placement, and mean atrial valve (AV) gradient before and after the procedure. Results: In the nCPAP group, the average length of stay was 2.79 days vs 2.71 days in the nasal cannula group. In the nCPAP group, no patient required a permanent pacemaker, while the nasal cannula group had a 40% rate of permanent pacemaker placement. The average preprocedure AV gradient was 51.14 in the nCPAP group and 42.57 in the nasal cannula group. The average postprocedure AV gradient was 8.5 in the nCPAP group and 5.36 in the nasal cannula group. Both groups had an intensive care unit admission rate of 0%. The rate of paravalvular leak was 35.7% in the nCPAP group and 28.6% in the nasal cannula group. The nCPAP group had an average of 0 episodes of hypoxia and the nasal cannula group had an average of 0.93 episodes of hypoxia. Conclusion: The findings demonstrate the viability of nCPAP as an effective method of oxygenation during intravenous sedation of TAVR patients when compared to oxygenation achieved via nasal cannula during TAVRs.

Comparison of Echocardiographic and Catheter Mean Gradient to Assess Stenosis After Transcatheter Aortic Valve Implantation.

Discordance exists between Doppler-derived and left heart catheterization (LHC)-derived mean gradient (MG) in transcatheter aortic valve implantation (TAVI). We compared echocardiographic parameters of prosthetic valve stenosis and LHC-derived MG in new TAVIs. In a retrospective, single-center study, intraoperative transesophageal echocardiogram (TEE)-derived MG, LHC-derived MG, and acceleration time (AT) were obtained before and after TAVI in 362 patients. Discharge MG, AT, and Doppler velocity index (DVI) using transthoracic echocardiogram (TTE) were also obtained. MG ≥10 mm Hg was defined as abnormal. During native valve assessment with pre-TAVI TEE and pre-TAVI LHC, Pearson correlation coefficient revealed a nearly perfect linear relation between both methods' MGs (r = 0.97, p <0.0001). Intraoperatively, after TAVI, Spearman correlation coefficient revealed a weak-to-moderate relation between post-TAVI TEE and LHC MGs (r = 0.33, p <0.0001). Significant differences were observed in categorizations between post-TAVI TEE MG and post-TAVI AT (McNemar test p = 0.0003) and between post-TAVI TEE MG and post-TAVI LHC MG (signed-rank test p <0.0001), with TEE MG more likely to misclassify a patient as abnormal. At discharge, 30% of patients had abnormal TTE MG, whereas 0% and 0.8% of patients had abnormal DVI and AT, respectively. Discharge TTE MG was not associated with death or hospitalization for heart failure at a median follow-up of 862 days. Post-TAVI Doppler-derived MG by intraoperative TEE was higher than LHC, despite being virtually identical before implantation. At discharge, patients were more likely to be classified as abnormal using MG than DVI and AT. Elevated MG at discharge was not associated with death or hospitalization for heart failure.

Combined Tricuspid Valve Repair and Orthotopic Liver Transplantation in a Patient With Severe Tricuspid Regurgitation and Pulmonary Hypertension.

Severe pulmonary hypertension and severe tricuspid regurgitation are often considered strict contraindications for orthotopic liver transplantation. A combined approach of tricuspid repair and subsequent liver transplantation could provide a novel approach for patients with severe pulmonary hypertension and tricuspid regurgitation to undergo orthotopic liver transplantation. A 62-year-old male with a history of end-stage renal disease on hemodialysis, cirrhosis, and third-degree atrioventricular heart block status post single lead pacemaker insertion presented for an orthotopic liver transplant. However, after placement of a Swan-Ganz catheter by the anesthesia team, the patient's central venous pressure was found to be high, and his mean pulmonary artery pressure was 40 mmHg. His case was canceled due to concern for poor postoperative outcomes after a subsequent transesophageal echocardiogram revealed a severely dilated right heart and 4+ tricuspid regurgitation with flow reversal into the hepatic veins. After discussion among the hospital's transplant committee, the patient was planned to have a tricuspid valve repair, liver transplant, and kidney transplant surgery several months later. The patient successfully underwent tricuspid valve repair and orthotopic liver transplant and then kidney transplant the following day.

Comparison of outcomes after transcatheter aortic valve implantation following home versus non-home discharge.

As more patients undergo transcatheter aortic valve implantation (TAVI), knowledge of 1-year mortality and associated factors becomes increasingly important. After other cardiac procedures, discharge location has been shown to be associated with 1-year mortality. We examined outcomes of TAVI patients discharged home vs an extended care facility (ECF). All TAVI patients from January 1, 2012, to December 31, 2017, were evaluated. Cox proportional hazard regression models with cubic splines were used to estimate the adjusted effect of discharge to ECF on 1-year mortality. A total of 957 (85.6%) patients discharged home were compared to 160 (14.3%) discharged to ECF. On univariate analysis, patients discharged home were younger and had a lower Society of Thoracic Surgeons Predicted Risk of Mortality, higher albumin, and fewer vascular complications and strokes. Patients discharged to ECF had a higher 30-day mortality (3.8% vs. 0.5%, P = 0.001) and 1-year mortality (25.7% vs. 8.3%, P < 0.001). Cox proportional hazard regression models showed increased risk of 1-year mortality for patients discharged to ECF. In conclusion, patients discharged to ECF had a higher 30-day and 1-year mortality. The strongest predictor of 1-year mortality was discharge to ECF. Society of Thoracic Surgeons Predicted Risk of Mortality score was not a predictor of 1-year mortality.

Hybrid intervention approach to coronary artery and valvular heart disease.

Coronary angiography is used to assess the burden of coronary artery disease prior to surgical valve repair/replacement and often leads to concomitant bypass and valve surgery. We sought to evaluate outcomes of an alternative, hybrid approach involving percutaneous coronary intervention (PCI) and valve surgery, assessing the rate of stent thrombosis as a primary outcome. We reviewed charts of consecutive patients who underwent planned PCI prior to surgical valve repair/replacement by a single surgeon from January 2008 to December 2016. We calculated rates of surgical complication, duration of dual antiplatelet therapy (DAPT) prior to surgery, and rates of stent thrombosis and in-stent restenosis. Twenty-four patients were included in this study. Surgery was performed a median of 52.5 days following PCI. DAPT was withheld an average of 8 days before and resumed an average of 4 days after surgery. Ninety-two percent of surgeries were minimally invasive. There were no bleeding complications, stent thromboses, or restenosis events. All patients survived the 1-year follow-up. For patients with mixed coronary and valvular heart disease, a heart team approach involving preoperative PCI followed by staged minimally invasive valvular surgery appears to be safe and warrants further exploration.

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.

Clinical Relevance of Baseline TCP in Transcatheter Aortic Valve Replacement.

AIMS: To investigate the influence of baseline thrombocytopenia (TCP) on short-term and long-term outcomes after transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: A total of 732 consecutive patients with severe, symptomatic aortic stenosis undergoing TAVR from January 2012 to December 2015 were included. Primary outcomes of interest were the relationship of baseline TCP with 30-day and 1-year all-cause mortality. Secondary outcomes of interest were procedural complications and in-hospital mortality in the same subgroups. The prevalence of TCP (defined as platelet count <150 × 109/L) at baseline was 21.9%, of whom 4.0% had moderate/severe TCP (defined as platelet count <100 × 109/L). Compared to no or mild TCP, moderate/severe TCP at baseline was associated with a significantly higher 30-day mortality (23.3% vs 2.3% and 3.1%, respectively; P<.001) and 1-year mortality (40.0% vs 8.3% and 13.4%, respectively; P<.001). In Cox regression analysis, moderate/severe baseline TCP was an independent predictor of 30-day and 1-year mortality (hazard ratio [HR], 13.18; 95% confidence interval [CI], 4.49-38.64; P<.001 and HR, 5.90; 95% CI, 2.68-13.02; P<.001, respectively). CONCLUSIONS: In conclusion, baseline TCP is a strong predictor of mortality in TAVR patients, possibly identifying a specific subgroup of frail patients; therefore, it should be taken into account when addressing TAVR risk.

One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease.

BACKGROUND: End-stage renal disease (ESRD) poses unique challenges in the treatment of patients with severe aortic stenosis. Although surgical valve replacement in ESRD patients has been associated with increased mortality, the outcomes from transcatheter aortic valve replacement (TAVR) are not clearly defined. METHODS: The CoreValve US Expanded Use Study is a prospective, nonrandomized study of TAVR in extreme-risk patients with comorbidities excluding them from the Pivotal Trial. We report on patients with ESRD. The primary endpoint was a composite of all-cause mortality or major stroke at 1 year. RESULTS: Ninety-six patients with ESRD underwent TAVR with the CoreValve (Medtronic, Minneapolis, MN) and have reached 1-year follow-up. Mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 16.2% ± 8.4%. The rate of all-cause mortality or major stroke at 1 year was 30.3%. The all-cause mortality rate was 5.3% at 30 days and 30.3% at 1 year. The rate at 1 year of any stroke or transient ischemic attack was 2.1%; major vascular injury was 5.2%; and new permanent pacemaker was 26.8%. Valve performance improved postprocedure and remained improved at 1 year (effective orifice area 1.71 cm2, mean gradient 9.33 mm Hg) CONCLUSIONS: Early mortality in patients with ESRD is comparable to previously published data on extreme-risk patients without ESRD, but our data suggest a higher mortality rate at 1 year for ESRD patients, likely due to comorbid conditions. Stroke and major vascular injury are infrequent, and improved valve hemodynamics are maintained at 1 year.

The heaviest known operatively-excised aortic valve.

A 60-year-old man whose operatively excised stenotic and regurgitant aortic valve weighed nearly 15 g, approximately 30 times the normal weight in an adult, is described. To the investigators' knowledge, this is the heaviest aortic valve ever encountered in a human being.

Transmyocardial laser revascularization causes sustained VEGF secretion.

Transmyocardial laser revascularization (TMR) using a carbon dioxide (CO(2)) laser has been shown to relieve angina, increase vascular density, and improve myocardial contraction. A study of 28 patients receiving TMR was conducted to monitor vascular endothelial growth factor (VEGF) levels with the goal of clarifying the relationship between TMR, the amelioration of angina, and vascular density. Serum VEGF levels were measured during four periods (preoperative, postoperative, convalescence, and late) in these 28 patients who received sole therapy TMR for un-revascularizable ischemic angina and the levels were compared with the control group consisting of 10 nonischemic thoracotomy patients. Twelve of the 28 patients had previous coronary artery bypass graft(s); 10 had unstable angina, and 1 had an ejection fraction less than 30%. Overall, angina class was reduced from 3.8 +/- 0.9 to 1.0 +/- 0.9 (P < 0.01) at the 1-year follow-up. There were no perioperative mortalities; however, there was one late mortality. The results show that VEGF levels were higher in the convalescence and late periods. Specifically in the late period, VEGF levels in TMR therapy patients surpassed those of the control group and normalized VEGF levels were three times higher in the late period than preoperatively. The sustained VEGF secretion observed in this study may help to explain why CO(2) TMR therapy causes locally increased vascular density and angina relief.

Tracheal resection in the morbidly obese patient: the role of dexmedetomidine.

We present a case of respiratory distress in a morbidly obese woman, which was complicated by a severe tracheal stenosis of the third to sixth cartilage. She had a history of sleep apnea and could only breathe sitting upright. An anesthetic, technique using dexmedetomidine was selected because of its properties of anxiolysis and sedation, with lack of respiratory depression. No intraoperative or postoperative opioids were required. Dexmedetomidine in high doses offers another approach to managing the patient with a compromised airway. Opioids were avoided in this patient, who was at major risk of postoperative respiratory depression and sleep apnea.

Migration of an amplatzer septal occluder device for closure of atrial septal defect into the ascending aorta with formation of an aorta-to-right atrial fistula.

The percutaneous closure of atrial septal defects is increasingly used. Serious complications of the procedure, such as cardiac perforation and tamponade, are rare and usually occur <72 hours after device placement. The investigators report the late development of the erosion of an Amplatzer septal occluder into the ascending aorta with associated aortic-to-right atrial fistula formation.

Late (>or=6 years) results of combined coronary artery bypass grafting and mitral valve replacement for severe mitral regurgitation secondary to acute myocardial infarction.

Analysis of outcomes in 31 patients who had combined mitral valve replacement (MVR) and coronary artery bypass grafting (CABG) for ischemic mitral regurgitation (MR) disclosed that 12 patients had MR because of papillary muscle rupture and that 19 patients had MR because of papillary muscle necrosis or fibrosis without rupture. Of the 12 patients with rupture, 6 died within 2 months of operation and the other 6 lived >or=6 years postoperatively; of the 19 patients without rupture, none died within 2 months of operation and 11 (58%) lived at least 6 years.

Epicardial atrial defibrillation: successful treatment of postoperative atrial fibrillation.

BACKGROUND: Atrial fibrillation is the most common complication after cardiac surgery. Current medical treatment using antiarrhythmics and anticoagulants has a significant morbidity. The goal of this study was to determine if epicardial atrial defibrillation can be safely performed and return patients to sinus rhythm. METHODS: A prospective analysis of patients undergoing cardiac surgery was performed. Patients with a prior pacemaker/defibrillator, history of arrhythmia, preoperative antiarrhythmic, age greater than 85 years, history of stroke, or intraaortic balloon pump were excluded. Temporary epicardial atrial cardioversion wires were placed on the right and left atrium. Bipolar atrial and ventricular pacing wires were also placed. The wires were tested in the operating room. Patients who went into postoperative arial fibrillation were cardioverted with 3 J, 6 J, or 9 J. RESULTS: There were 45 patients enrolled. Sixteen patients (35%) went into postoperative arial fibrillation during their hospital stay. Mean time to onset of arial fibrillation was 2.6 +/- 1.4 days after surgery. Fifteen patients were successfully cardioverted to sinus rhythm on the primary cardioversion, with mean of 5.7 +/- 2.4 J. One patient was cardioverted at 6 hours after onset of arial fibrillation, at 6 J. Recurrent arial fibrillation occurred in 4 patients during their hospital stay. All 4 of these patients were cardioverted with a mean of 6.4 +/- 2.6 J. All wires were removed the day before patients were discharged. There were no complications with wire insertion or removal. There were no adverse neurologic events. The mean hospital stay was 5.1 +/- 2.2 days. All patients were in sinus rhythm at 1 month follow-up. CONCLUSIONS: The use of a temporary atrial defibrillator to resynchronize patients in postoperative arial fibrillation is safe and effective.

Clinical benefits of leukocyte filtration during valve surgery.

BACKGROUND: The accumulation of activated leukocytes in the pulmonary circulation plays an important role in the pathogenesis of lung dysfunction associated with cardiopulmonary bypass (CPB). Patients undergoing valve surgery have prolonged CPB owing to the complexity of the surgery. The goal of this study is to determine if arterial leukocyte filters during CPB improve clinical outcomes after valve surgery. METHODS: A prospective analysis of all patients receiving only valve surgery with leukocyte arterial filters from June 1999 to June 2002 was compared with a case matched cohort during the same time period. Two hundred fifty patients were identified and compared with a cohort who did not have leukocyte filters used during CPB. The following study points were evaluated preoperatively and postoperatively: white blood cell count, platelet count, arterial blood gas, time to extubation, intensive care unit stay, and total length of hospital stay. RESULTS: There were 500 patients in the study. The following valve operations were performed: 92 mitral valve replacements, 168 aortic valve replacements, 152 mitral valve repairs, 80 combined valve repair/replacements, and 8 tricuspid valve repairs, all evenly divided between the two treatment limbs. Patients with leukocyte filters had the following findings compared with nonfilter patients: The time to extubation 10.3 versus 16.2 hours (P = 0.009), postoperative respiratory quotient 407 versus 320 (P = 0.02), total length of stay 5.4 versus 7.2 days (P = 0.04). CONCLUSIONS: The use of arterial leukocyte filters in patients undergoing valve surgery leads to earlier extubation, improved oxygenation, and a decreased length of stay. Leukocyte filters should be used during CPB for patients having valve surgery.

Gross and histological features of excised portions of posterior mitral leaflet in patients having operative repair of mitral valve prolapse and comments on the concept of missing (= ruptured) chordae tendineae.

OBJECTIVES: The aim of the study is to describe gross and histological features of operatively excised portions of mitral valves in patients with mitral valve prolapse (MVP). BACKGROUND: Although numerous articles on MVP (myxomatous or myxoid degeneration, billowing or floppy mitral valve) have appeared, 2 virtually constant histological features have been underemphasized or overlooked: 1) the presence of superimposed fibrous tissue on both surfaces of the leaflets and surrounding many chordae tendineae; and 2) the absence of many chordae tendineae on the ventricular surfaces of the leaflets as the result of their being hidden (i.e., covered up) by the superimposed fibrous tissue. METHODS: We examined operatively excised portions of prolapsed posterior mitral leaflets in 37 patients having operative repair. RESULTS: Histological study of elastic-tissue stained sections disclosed that the leaflet thickening was primarily due to the superimposed fibrous tissue. All leaflets had variable increases in the spongiosa element within the leaflet itself with some disruption and/or loss of the fibrosa element and occasionally complete separation of it from the spongiosa element. Both the leaflet and chordae were separated from the superimposed fibrous tissue by their black-staining elastic membranes. CONCLUSIONS: These findings demonstrate that the posterior leaflet thickening in MVP is mainly due to the superimposed fibrous tissue rather than to an increased volume of the spongiosa element of the leaflet itself. The superimposed fibrous tissue on both leaflet and chordae is likely the result of subsequent abnormal contact of the leaflets and chordae with one another. Chordal rupture (i.e., missing chordae) occurred in all 37 patients, but finding individual ruptured chords was rare.

Dexmedetomidine infusion for analgesia up to 48 hours after lung surgery performed by lateral thoracotomy.

Patients undergoing a lateral thoracotomy for pulmonary resection have moderate to severe pain postoperatively that is often treated with opioids. Opioid side effects such as respiratory depression can be devastating in patients with already compromised respiratory function. This prospective double-blinded clinical trial examined the analgesic effects and safety of a dexmedetomidine infusion for postthoracotomy patients when administered on a telemetry nursing floor, 24 to 48 hours after surgery, to determine if the drug's known early opioid-sparing properties were maintained. Thirty-eight thoracotomy patients were administered dexmedetomidine intraoperatively and overnight postoperatively and then randomized to receive placebo or dexmedetomidine titrated from 0.1 to 0.5 µg·kg·h(-1) the day following surgery for up to 24 hours on a telemetry floor. Opioids via a patient-controlled analgesia pump were available for both groups, and vital signs including transcutaneous carbon dioxide, pulse oximetry, respiratory rate, and pain and sedation scores were monitored. The dexmedetomidine group used 41% less opioids but achieved pain scores equal to those of the placebo group. The mean heart rate and systolic blood pressure were lower in the dexmedetomidine group but sedation scores were better. The mean respiratory rate and oxygen saturation were similar in the two groups. Mild hypercarbia occurred in both groups, but periods of significant respiratory depression were noted only in the placebo group. Significant hypotension was noted in one patient in the dexmedetomidine group in conjunction with concomitant administration of a beta-blocker agent. The placebo group reported a higher number of opioid-related adverse events. In conclusion, the known opioid-sparing properties of dexmedetomidine in the immediate postoperative period are maintained over 48 hours.

Combined congenitally bicuspid aortic valve and mitral valve prolapse causing pure regurgitation.

Described herein is a patient with a purely regurgitant congenitally bicuspid aortic valve and a purely regurgitant prolapsing mitral valve. Although it is well established that the bicuspid aortic valve is a congenital anomaly, it is less well appreciated that mitral valve prolapse is almost certainly also a congenital anomaly. The two occurring in the same patient provides support that mitral valve prolapse is also a congenital anomaly.

Necropsy findings early after transcatheter aortic valve implantation for aortic stenosis.

Although transcatheter aortic valve implantation has been available for 10 years, reports of cardiovascular morphologic studies after the procedure are virtually nonexistent. The investigators describe such findings in 2 patients, both 86 years of age, who died early (hours or several days) after transcatheter aortic valve implantation. Although the prosthesis in each was seated well, and each of the 3 calcified cusps of the native aortic valves was well compressed to the wall of the aorta, thus providing a good bioprosthetic orifice, the ostium of the dominant right coronary artery in each was obliterated by the native right aortic valve cusp. Atherosclerotic plaques in the common iliac artery led to a major complication in 1 patient, who later died of hemorrhagic stroke. The other patient developed fatal cardiac tamponade secondary to perforation of the right ventricular wall by a pacemaker catheter.