Mid-term outcomes of concomitant Cox-Maze IV: Results from a multicenter prospective registry.

BACKGROUND: Benefits of concomitant atrial fibrillation (AF) surgical treatment are well established. Cardiac societies support treating AF during cardiac surgery with a class I recommendation. Despite these guidelines, adoption has been inconsistent. We report results of routine performance of concomitant Cox-Maze IV (CMIV) from participating centers using a standardized, prospective registry. METHODS: Nine surgeons at four cardiac surgery programs enrolled 807 patients undergoing concomitant CMIV surgery over 12 years. Lesions were created using bipolar radiofrequency clamps and cryoablation probes. Follow-up occurred at 3- and 6-months, then annually for 3 years. Freedom from AF was defined as no episode >30 s of atrial arrhythmia. RESULTS: Sixty-four percent of patients were male, mean age 69 years, mean left atrial size 4.6 cm, mean preoperative AF duration 4.0 years, mean EuroSCORE 6.4, and mean CHADS2 score 3.1. Thirty-day postoperative mortality and neurologic event rates were 3.3% and 1.3%, respectively. New pacemaker implant rate was 6.3%. Freedom from AF rates at 1- and 3-years stratified by preoperative AF type were: paroxysmal 94.6% and 87.5%, persistent 82.1% and 81.9%, and longstanding persistent 84.1% and 78.1%. At 3-year follow up, 84% of patients were off antiarrhythmic drugs and 74% of sinus rhythm patients were off oral anticoagulants. CONCLUSIONS: Routine CMIV is safe and effective. Acceptable outcomes can be achieved across multiple centers and multiple operators even in a moderate risk patient population undergoing more complex procedures. Surgeons and institutions should be encouraged by all cardiac societies to adopt the CMIV procedure to maximize patient benefit.

Long-term Results With CorMatrix Extracellular Matrix Patches After Carotid Endarterectomy.

BACKGROUND: Previous reports of extracellular matrix (ECM) patch use after carotid endarterectomy (CEA) have noted an approximately 10% rate of pseudoaneurysm (PSA) formation. PSA-related rupture of ECM patches has also been described after femoral artery repair. In these studies, different thicknesses (4-ply versus 6-ply) and no standard length of soaking the patch in saline before implantation were used. Herein, we describe our experience with ECM CorMatrix patches in 291 CEAs with 6-ply patches. METHODS: The records of 275 consecutive patients undergoing 291 CEAs with CorMatrix 6-ply patches beginning in November of 2011 and extending until 2015 were reviewed. Only 6-ply patches and a 1 min hydration time in saline were used in all patients. No shunts were used. RESULTS: There were three deaths within the first 30 d secondary to subsequent cardiac surgical procedures. Nine patients experienced a perioperative stroke (3.1%), only one of which occurred secondary to an occluded internal carotid artery. One patient had a transient ischemic attack with a patent endarterectomy site. In follow-up, 11 patients (4.5%) developed severe recurrent stenoses requiring reintervention. Only one patient (0.34%) developed a PSA at 2 years possibly secondary to chronic infection. The median follow-up was 72 mo. CONCLUSIONS: Our experience with 6-ply CorMatrix ECM patches and a brief period of soaking demonstrated that these patches performed well in patients requiring a CEA. Only one PSA was noted.

Rigid Sternal Fixation and Enhanced Recovery for Opioid-Free Analgesia After Cardiac Surgery.

BACKGROUND: We evaluated the individual contributions of rigid-plate fixation (RPF) and an enhanced recovery protocol (ERP) on postoperative pain, opioid use, and other outcomes after median sternotomy as they were sequentially adopted into practice. METHODS: This single-center, retrospective, case-cohort study compared outcomes between median sternotomy patients (all comers) who underwent operation before implementation of RPF or ERP ("controls"), patients closed with RPF before ERP implementation ("RPF-only"), and patients managed with RPF and ERP during early "RPF+ERP-2020" and late "RPF+ERP-2022" implementation. RESULTS: The analysis included 608 median sternotomy patients (mean age, 65.7 ± 10.8 years; 29.6% women). Of those, 59.2% were isolated coronary artery bypass grafting, 7.7% were isolated valve procedures, and the rest were mixed/concomitant procedures. Median in-hospital, postoperative opioid administration was 172.5 morphine milligram equivalents (MMEs) in the control cohort vs 0 MMEs for RPF+ERP-2022 (P < .0001), despite similar or slightly reduced patient-reported pain scores. The proportion of patients discharged directly to home was 66.2% for controls, 79.6% for RPF-only (P = .010), and 93.5% for RPF+ERP-2022 (P < .0001). Median opioids prescribed at discharge were 600 MMEs for controls and 0 for RPF+ERP-2020 and RPF+ERP-2022 (P < .0001). At discharge, 86.7% of RPF-only patients received prescription opioids vs 5% in RPF+ERP-2020 and 4.3% RPF+ERP-2022 (P < .0001). These outcomes occurred without increased readmissions. CONCLUSIONS: Systematic implementation of RPF and ERP was associated with a significant and clinically meaningful decrease in opioid use in this large, real-world patient population.

Advanced artificial intelligence-guided hemodynamic management within cardiac enhanced recovery after surgery pathways: A multi-institution review.

Objective: The study objective was to report early outcomes of integrating Hypotension Prediction Index-guided hemodynamic management within a cardiac enhanced recovery pathway on total initial ventilation hours and length of stay in the intensive care unit. Methods: A multicenter, historical control, observational analysis of implementation of a hemodynamic management tool within enhanced recovery pathways was conducted by identifying cardiac surgery cases from 3 sites during 2 time periods, August 1 to December 31, 2019 (preprogram), and April 1 to August 31, 2021 (program). Reoperations, emergency (salvage), or cases requiring mechanical assist were excluded. Data were extracted from electronic medical records and chart reviews. Two primary outcome variables were length of stay in the intensive care unit (using Society of Thoracic Surgeons definitions) and acute kidney injury (using modified Kidney Disease Improving Global Outcomes criteria). One secondary outcome variable, total initial ventilation hours, used Society of Thoracic Surgeons definitions. Differences in length of stay in the intensive care unit and total ventilation time were analyzed using Kruskal-Wallis and stepwise multiple linear regression. Acute kidney injury stage used chi-square and stepwise cumulative logistic regression. Results: A total of 1404 cases (795 preprogram; 609 program) were identified. Overall reductions of 6.8 and 4.4 hours in intensive care unit length of stay (P = .08) and ventilation time (P = .03) were found, respectively. No significant association between proportion of patients identified with acute kidney injury by stage and period was found. Conclusions: Adding artificial intelligence-guided hemodynamic management to cardiac enhanced recovery pathways resulted in associated reduced time in the intensive care unit for patients undergoing nonemergency cardiac surgery across institutions in a real-world setting.

Extracellular Matrix Patches for Endarterectomy Repair.

Patch repair is the preferred method for arteriotomy closure following femoral or carotid endarterectomy. Choosing among available patch options remains a clinical challenge, as current evidence suggests roughly comparable outcomes between autologous grafts and synthetic and biologic materials. Biologic patches have potential advantages over other materials, including reduced risk for infection, mitigation of an excessive foreign body response, and the potential to remodel into healthy, vascularized tissue. Here we review the use of decellularized extracellular matrix (ECM) for cardiovascular applications, particularly endarterectomy repair, and the capacity of these materials to remodel into native, site-appropriate tissues. Also presented are data from two post-market observational studies of patients undergoing iliofemoral and carotid endarterectomy patch repair as well as one histologic case report in a challenging iliofemoral endarterectomy repair, all with the use of small intestine submucosa (SIS)-ECM. In alignment with previously reported studies, high patency was maintained, and adverse event rates were comparable to previously reported rates of patch angioplasty. Histologic analysis from one case identified constructive remodeling of the SIS-ECM, consistent with the histologic characteristics of the endarterectomized vessel. These clinical and histologic results align with the biologic potential described in the academic ECM literature. To our knowledge, this is the first histologic demonstration of SIS-ECM remodeling into site-appropriate vascular tissues following endarterectomy. Together, these findings support the safety and efficacy of SIS-ECM for patch repair of femoral and carotid arteriotomy.

Using Aspiration-Based Tricuspid Valve Endocarditis Debridement: Highlighting Imaging-Based Modification in a High-Risk Clinical Scenario.

This report describes a high-risk case of tricuspid valve endocarditis secondary to intravenous drug abuse. Information gleaned from intraoperative transesophageal echocardiographic imaging and real-time measurements was used to effectively modify procedural hardware and successfully treat the patient using an aspiration-based strategy. (Level of Difficulty: Advanced.).

Selective management of penetrating truncal injuries: is emergency department discharge a reasonable goal?

We undertook this retrospective review to examine the appropriateness of a protocol for the selective emergency department (ED) workup of asymptomatic penetrating truncal injuries. Records of consecutive patients presenting to our urban Level I trauma center with penetrating truncal injuries between January 1, 1997 and September 2000 were reviewed. Data obtained included: patient demographics, ED workup, ED disposition, complications, and follow-up. Selective ED workup included hospital triple-contrast CT, admission for observation, and local wound exploration for selected anterior abdominal stab wounds. Four hundred fifty-five patients presented with penetrating truncal wounds during the study period. One hundred ninety-four patients were taken directly to the operating room, 136 were discharged based solely on physical examination and plain radiographs, 18 were admitted for observation without ED workup, and 107 had selective ED workup. Sixty-two patients (58% of those selectively worked up) were discharged home after negative ED workup, 18 were managed operatively, and 27 were managed nonoperatively. There were two missed injuries that were later identified and managed with no complications. Follow-up was available on 66 per cent of ED workup patients (range 1-42 months). We conclude that selective management of certain penetrating truncal injuries appears appropriate. Patients having a negative selective ED workup can be safely discharged thereby avoiding the cost and resource utilization associated with hospital admission.

Evaluation of vascular injury in penetrating extremity trauma: angiographers stay home.

The debate over the use of diagnostic angiography (DA) to exclude arterial injury in penetrating extremity trauma (PET) continues. This review evaluates our current protocol for PET and identifies indications for DA. Patients presenting to our urban Level I trauma center between January 1997 and September 2000 with PET were included. Demographic data, emergency department (ED) course, and patient follow-up were reviewed. ED evaluation directed by physical examination (PE) included Doppler pressure indices (DPI) and DA if indicated. A total of 538 patients had PET injuries. Twenty (4%) patients with hard signs of vascular injury were taken to the operating room. Ninety-one (17%) patients without vascular compromise underwent operative procedures or were admitted for other injuries. One hundred twenty-three (23%) patients with nonproximity wounds were discharged. Four DAs were performed for abnormal DPI with no change in management. Three hundred patients with a negative PE and normal DPI were discharged from the ED. Follow-up was available on 51 per cent of these patients (range 1-49 months) with no missed injuries identified. We conclude that PE with DPI is an appropriate way to identify significant vascular injuries from PET. Patients with normal PE and DPI can be safely discharged. DA is only indicated for asymptomatic patients with abnormal DPI.

Impact of hypercalcemia and parathyroid hormone level on the sensitivity of preoperative sestamibi scanning for primary hyperparathyroidism.

Technetium 99m sestamibi scanning (MIBI) can direct unilateral parathyroidectomy. However, the clinical application remains variable with sensitivities ranging from 55 to 100 per cent. We examined whether patient factors including serum calcium (Ca) and parathyroid hormone (PTH) levels impact the sensitivity of MIBI. We completed a retrospective review of 102 patients with primary hyperparathyroidism and mild hypercalcemia who underwent preoperative MIBI. All patients underwent bilateral neck explorations with abnormalities confirmed by histopathology. MIBI sensitivity was correlated with preoperative Ca and PTH levels using univariate and logistic regression analysis. The mean preoperative Ca was 11.0 mg/dL and the mean PTH was 158 pg/mL. More than 95 per cent of patients with Ca greater than 11.3 mg/dL had a positive scan as compared with 60 per cent of those with lesser values (P = 0.0024). Similarly a serum PTH level greater than 160 pg/mL correlated with positive scans in 93 per cent as opposed to 57 per cent in those with lower levels (P = 0.006). Using a scan-directed approach 65 of 74 patients would have undergone unilateral exploration; this would yield a 7.7 per cent operative failure rate because of contralateral multigland disease. Lower Ca and PTH levels seem to correlate with reduced sensitivity of MIBI. Increasing acceptance of surgery for hyperparathyroidism with minimal hypercalcemia may make MIBI less attractive without ancillary diagnostic measures such as rapid parathormone assays.

Postoperative surveillance of differentiated thyroid carcinoma: a selective approach.

This review was conducted to evaluate the selective use of 131I whole-body scanning (WBS) and radioablation (RA) after thyroidectomy for patients with differentiated thyroid carcinoma (DTC). A review of patients undergoing thyroidectomy for DTC between July 1, 1980 and December 31, 1999 was performed. Postoperative surveillance involved a selective RA protocol based on a modification of the AMES criteria (age, metastases, extent of cancer, size, and multifocality of tumor). Lower-risk patients were followed by yearly thyroglobulin (Tg) levels and physical examinations (PE) whereas higher-risk patients additionally underwent WBS and RA when appropriate. Three hundred forty-three patients were identified; of these 27 per cent had positive lymph nodes or metastatic disease at their initial operation. Two hundred thirteen (64%) patients underwent postoperative WBS with 174 (82%) requiring RA. One hundred thirty (36%) low-risk patients were followed with yearly Tg and PE that when abnormal led to WBS and RA. No additional patient morbidity or mortality resulted from this protocol. Factors identified during multivariate analyses as being predictive of occult metastasis and recurrence (P < 0.05) included tumor size and lymph node status. These data support a selective approach to the postoperative surveillance of DTC using Tg and PE to monitor low-risk patients and WBS for those with a higher risk of recurrence.

Indicators for tracheostomy in patients with traumatic brain injury.

Our objective was to develop criteria to identify patients with traumatic brain injury (TBI) who require a tracheostomy (TR). From January 1994 to May 2000 all TBI patients requiring intubation on presentation and who survived >7 days were identified from our trauma registry. Demographics, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and ventilator days, ICU days, hospital days, need for TR, and development of pneumonia were statistically analyzed. Of 246 patients with TBI 211 without TR and 35 with TR were identified (mean time to TR 13.3+/-7.0 days). Logistic regression analysis identified presenting GCS < or =8, ISS > or =25, and ventilator days >7 as significant predictors for TR. Applying these three predictors to our population identified 48 patients (21 with TR, 18 without TR, and nine who died on the ventilator without TR) with a sensitivity of 60 per cent, a specificity of 87 per cent, a positive predictive value of 44 per cent, and a negative predictive value of 93 per cent. Patients with TR had lower presenting GCS and higher ventilator, ICU, and hospital days (P < 0.05). Pneumonia rates were similar. Time to neurologic recovery (GCS > or =9) was longer for the TR patients as compared with the patients without TR. We conclude that patients with TBI presenting with a GCS < or =8, an ISS > or =25, and ventilator days >7 are more likely to require TR. Performing TR late did not reduce pneumonia rates or ventilator, ICU, or hospital days. By identifying the at-risk population early TR could be performed in an attempt to decrease morbidity and length of stay.

Adrenal insufficiency in patients with ruptured abdominal aortic aneurysms.

PURPOSE: Failure of the adrenocortical system after open repair of ruptured abdominal aortic aneurysm (RAAA) has never been reported, to our knowledge. This study was undertaken to examine the incidence and response to treatment of adrenal insufficiency in the RAAA population. METHODS: A 6-year retrospective analysis was carried out on data for all patients admitted after RAAA repair. A cosyntropin stimulation test (CST) was performed in patients with unexplained postoperative hypotension. Patients with adrenal insufficiency were given stress dose hydrocortisone, followed by slow hydrocortisone taper. RESULTS: Twenty of 26 patients admitted after RAAA repair survived longer than 1 week. Nine of these 20 patients underwent CST because of unexplained hypotension, and six patients were found to have adrenal insufficiency. Compared with the three patients with normal CST and the 11 patients with normotension who did not require testing, patients with adrenal insufficiency had greater preoperative hypotension (83% vs 29%; P =.05), greater operative blood loss (7.0 +/- 1.6 L vs 3.0 +/- 0.9 L; P =.003), longer lower extremity ischemia time (5.0 +/- 2.3 hours vs 1.3 +/- 0.5 hours; P =.025), and lower intraoperative urine output (0.8 +/- 0.4 mL/kg/hr vs 2.1 +/- 0.6 mL/kg/hr; P =.023). No difference in length of stay (40 +/- 18 days vs 35 +/- 26 days), major complications (27% vs 32%), or overall mortality (17% vs 15%) was demonstrated with steroid therapy. Initiation of steroid therapy enabled weaning of vasopressor support within 48 hours in patients with adrenal insufficiency. CONCLUSIONS: Adrenal insufficiency was identified in 67% of patients with RAAA with unexplained postoperative hypotension given a CST. Predictors of adrenal insufficiency after RAAA repair include preoperative hypotension and a complicated operative course. Steroid therapy can limit vasopressor dependence, and is not associated with increased morbidity or mortality.

The role of endoscopic colon surveillance in the transplant population.

PURPOSE: Long-term immunosuppression increases the risks of developing certain malignancies. This study examines the effects of long-term immunosuppression on the development of metachronous adenomatous polyps and attempts to formulate a sound surveillance plan for these individuals. METHOD: A retrospective analysis was performed of all solid organ transplant patients at Henry Ford Hospital from 1989 to 1999, with a specific focus on endoscopic evaluation and outcomes after three years of surveillance. Comparison was made to an age-matched and gender-matched control group from the same endoscopic database. Variables were compared using the chi-squared test, Fisher's exact probability test, and Hochberg's test. RESULTS: A total of 992 solid organ transplants were performed. Two hundred twenty-nine (23 percent) of the transplant recipients underwent pretransplant colonoscopy, of which 178 patients (78 percent) were age 50 years or older. Seventy-four (32 percent) of the prescreened population had polyps, of which 45 patients (61 percent) had adenomas. Twenty-seven patients (36 percent) had synchronous polyps, of which 12 patients (16 percent) had synchronous adenomas. At 3-year follow-up 59 patients (80 percent) had metachronous polyps. Twenty-eight patients (38 percent) had metachronous adenomas. Eleven patients (15 percent) with hyperplastic polyps on initial colonoscopy developed adenomas. The control group consisted of 25 females and 50 males with a mean age of 65.5 +/- 1.1 years. Fifty-one patients (68 percent) had adenomas on endoscopy. Twenty-four patients (32 percent) had synchronous lesions, of which 13 patients (17 percent) had synchronous adenomas. Sixty-one patients (84 percent) developed metachronous lesions, of which 33 patients (43 percent) had metachronous adenomas at 3 years. There was no difference in the polyp size or histology between the two groups. There was no statistically significant difference between the transplant patients and the control group in all analyses. CONCLUSION: Because of an equivalent incidence of adenomatous polyps compared with the general population, current screening criteria should be used in patients posttransplant. Transplant patients are not more likely to develop metachronous polyps than the general population. Therefore, posttransplant polyp surveillance should not be more frequent than currently recommended for nontransplant patients with adenomatous polyps.

Outcome of carotid endarterectomy in African Americans: is race a factor?

OBJECTIVE: African American patients have been underrepresented in large-scale trials of carotid endarterectomy (CEA). Thus the role of CEA in the treatment of extracranial carotid artery occlusive disease in black patients remains unclear. We undertook this study to determine the effect of black race on early and late outcome of CEA. METHODS: A retrospective review was performed of records for patients who underwent CEA from 1990 to 1999. Data on demographics, operative indications, hospital course, and long-term follow-up were obtained for each patient. Patients were stratified by race for comparison of perioperative course and late outcome. Risk factors were compared using chi(2) methods, and life table analysis was performed with Kaplan-Meier survival plots. RESULTS: One thousand forty-five CEA procedures were performed during the study period, 133 (13%) in black patients and 912 (87%) in white patients. Demographic risk factors were similar in both groups, except for hypertension (P =.003), diabetes (P <.001), and renal insufficiency (P =.03), which were more prevalent in blacks. Just over half of patients had symptoms at presentation, with equal racial distribution. The perioperative stroke and death rate was 3.3% (blacks, 5.3%; whites, 3.1%; P =.19). The 8-year actuarial ipsilateral stroke rate was 7% in patients without symptoms and 8% in patients with symptoms, with no racial variation. There was, however, a racial difference in the long-term "all strokes" rate (P =.002), regardless of vascular territory. This difference was largely due to the high late stroke rate in black patients with symptoms at presentation. A Cox proportional hazards analysis showed that only black race was a significant predictor of any stroke. CONCLUSIONS: CEA can be accomplished with acceptable morbidity and mortality in black patients with an expectation of similar protection from ipsilateral ischemic stroke as in white patients. Black patients, however, have a higher incidence of all strokes at long-term follow-up due to the higher risk of stroke in patients with symptoms of carotid bifurcation disease.