Gender-related outcomes after open repair of descending thoracic and thoracoabdominal aortic aneurysms.

OBJECTIVE: Female sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: We searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long-term outcomes. RESULTS: From 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P < .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second <50% (28.3% vs 18.2%; P < .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P < .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41-5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53-9.10). Women also had significantly lower 5-year survival. CONCLUSIONS: Women undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period.

Three Arterial Grafts Improve Late Survival: A Meta-Analysis of Propensity-Matched Studies.

BACKGROUND: Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the long-term outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed. METHODS: A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for long-term mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals. RESULTS: Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71-1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75-0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33-0.98; P=0.04). CONCLUSIONS: The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and diabetic mellitus status.

Mechanisms, Consequences, and Prevention of Coronary Graft Failure.

Graft failure occurs in a sizeable proportion of coronary artery bypass conduits. We herein review relevant current evidence to give an overview of the incidence, pathophysiology, and clinical consequences of this multifactorial phenomenon. Thrombosis, endothelial dysfunction, vasospasm, and oxidative stress are different mechanisms associated with graft failure. Intrinsic morphological and functional features of the bypass conduits play a role in determining failure. Similarly, characteristics of the target coronary vessel, such as the severity of stenosis, the diameter, the extent of atherosclerotic burden, and previous endovascular interventions, are important determinants of graft outcome and must be taken into consideration at the time of surgery. Technical factors, such as the method used to harvest the conduits, the vasodilatory protocol, the storage solution, and the anastomotic technique, also play a major role in determining graft success. Furthermore, systemic atherosclerotic risk factors, such as age, sex, diabetes mellitus, hypertension, and dyslipidemia, have been variably associated with graft failure. The failure of a coronary graft is not always correlated with adverse clinical events, which vary according to the type, location, and reason for failed graft. Intraoperative flow verification and secondary prevention using antiplatelet and lipid-lowering agents can help reducing the incidence of graft failure.

Open repair of descending and thoracoabdominal aortic aneurysms in octogenarians.

OBJECTIVE: Despite improved outcomes for open repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA), these operations remain challenging in octogenarians. Patients unsuitable for thoracic endovascular aortic repair require open surgery to avoid catastrophic rupture. We analyzed our results for DTA/TAAA repair in these elderly patients. METHODS: Our institutional aortic database was queried to identify those ≥80 years old and those <80 years old undergoing open DTA/TAAA repair. Logistic and Cox regression analyses were used to account for confounders and to identify predictors of perioperative and long-term outcomes. RESULTS: From 1997 to 2017, there were 783 patients who underwent open repair of DTA or TAAA; 96 (12.3%) were ≥80 years old. Octogenarians were more likely to be female (P = .018), with chronic pulmonary disease (P = .012), severe peripheral vascular disease (P < .001), and hypertension (P = .025). Degenerative aneurysms were more common among octogenarians (P < .001), whereas chronic and acute dissections were more common among those younger than 80 years (P < .001 for both). Operative mortality was 5.6% and was not negatively affected by advanced age (<80 years, 5.7%; ≥80 years, 5.6%; P = .852). Other than an increased incidence of left recurrent nerve palsy in the younger cohort (<80 years, 6.7%; ≥ 80 years, 1.0%; P = .029), there were no significant differences in the incidence of major postoperative complications. Logistic regression modeling showed that age ≥80 years was not predictive of operative mortality or postoperative complications. A greater percentage of octogenarians had aortic reconstruction with a clamp and sew strategy (85.4% vs 61.6%; P < .001), which led to significantly shorter cross-clamp times in this cohort (26.6 minutes vs 30.7 minutes; P < .004). In octogenarians, the incidence of major postoperative adverse events was associated with extent II aneurysms (odds ratio, 2.6; P < .025). Short- and long-term survival was significantly reduced in octogenarians. CONCLUSIONS: In select octogenarians, open repair of DTA/TAAA can be performed with acceptable risk. A simplified surgical approach may provide the best opportunity for a successful outcome.

Endoscopic versus open radial artery harvesting: A meta-analysis of randomized controlled and propensity matched studies.

BACKGROUND: We sought to investigate the impact of radial artery harvesting techniques on clinical outcomes using a meta-analytic approach limited to randomized controlled trials and propensity-matched studies for clinical outcomes, in which graft patency was analyzed. METHODS: A systematic literature review was conducted using PubMed and MEDLINE to identify publications containing comparisons between endoscopic radial artery harvesting (ERAH) and open harvesting (ORAH). Only randomized controlled trials and propensity-matched series were included. Data were extracted and analyzed with RevMan. The primary endpoint was wound complication rate, while secondary endpoints were patency rate, early mortality, and long-term cardiac mortality. RESULTS: Six studies comprising 743 patients were included in the meta-analysis. Of them 324 (43.6%) underwent ERAH and 419 (56.4%) ORAH. ERAH was associated with a lower incidence of wound complications (odds ratio: 0.33, confidence interval 0.14-0.77; p = 0.01). There were no differences in graft patency, and early and long-term cardiac mortality between the two techniques. CONCLUSION: ERAH reduces wound complications and does not affect graft patency, or short- and long-term mortality compared to ORAH.

Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study.

BACKGROUND: The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. METHODS: We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. RESULTS: A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. CONCLUSIONS: Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.

Open radial artery harvesting better preserves endothelial function compared to the endoscopic approach.

OBJECTIVES: Both the open and endovascular techniques are commonly used for harvesting the radial artery (ORAH and ERAH, respectively), and yet, very little is known about the effects of these 2 techniques on endothelial integrity and function of the radial artery (RA). The aim of this study was to assess the endothelial integrity and function of RA harvested using the 2 approaches. METHODS: Two independent surgical teams working in the same institution routinely use the RA for coronary artery bypass grafting exclusively employing either ORAH or ERAH. Thirty-nine consecutive patients were enrolled in this comparative study. Endothelial function after ORAH or ERAH was assessed by using the wire myograph system. The integrity of the RA endothelium was evaluated by immunohistochemical staining for erythroblast transformation specific-related gene. RESULTS: The vasodilation in response to acetylcholine was significantly higher in RA harvested with ORAH (P ≤ 0.001 versus ERAH). Endothelial integrity was not different between the 2 groups. CONCLUSIONS: ORAH is associated with a significantly higher endothelium-dependent vasodilation. Further investigation on the potential implications of these findings in terms of graft spasm and patency as well as clinical outcomes are needed.

Percutaneous coronary intervention versus coronary bypass surgery for unprotected left main disease: a meta-analysis of randomized controlled trials.

BACKGROUND: This meta-analysis of randomized controlled trials (RCTs) was aimed at comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary disease. METHODS: All RCTs randomizing patients to any type of PCI with stents vs. CABG for left main disease (LMD) were included. Primary outcome was a composite of follow-up death/myocardial infarction/stroke/repeat revascularization. Secondary outcomes were peri-procedural mortality and the individual components of the primary outcome. Incidence rate ratio (IRR) or odds ratio (OR) and 95% confidence intervals (CIs) were pooled using a generic inverse variance method with random effects model. Subgroup analyses were done based on: (I) type of PCI [bare metal stents (BMS) vs. drug-eluting stents (DES)] and; (II) mean SYNTAX score tertiles. Leave one-out analysis and meta-regression were performed. RESULTS: Six trials were included (4,700 patients; 2,349 PCI and 2,351 CABG). Follow-up ranged from 2.33 to 5 years. PCI was associated with higher risk of follow-up death/myocardial infarction/stroke/repeat revascularization (IRR =1.328, 95% CI, 1.114-1.582, P=0.002) and of repeated revascularization (IRR =1.754, 95% CI, 1.470-2.093, P<0.001). The risk of peri-procedural mortality (OR =0.866, 95% CI, 0.460-1.628, P=0.654), follow-up mortality (IRR =0.947, 95% CI, 0.711-1.262, P=0.712), myocardial infarction (IRR =1.342, 95% CI, 0.827-2.179, P=0.234) and stroke (IRR =0.800, 95% CI, 0.374-1.710, P=0.565) were similar between groups. No differences were found between DES and BMS subgroups. The risk of follow-up death/myocardial infarction/stroke/repeat revascularization with PCI was higher in all SYNTAX tertiles, with a progressive increase from the 1st to the 3rd tertile. At meta-regression, higher mean SYNTAX score was associated with higher risk for the primary outcome in the PCI group (beta =0.02, P=0.05), whereas no association was found with female gender, mean age, or diabetes. CONCLUSIONS: CABG remains the therapy of choice for the treatment of unprotected LMD, especially for patients with a high SYNTAX score.

Retrograde Cerebral Perfusion Is Effective for Prolonged Circulatory Arrest in Arch Aneurysm Repair.

BACKGROUND: The optimal brain protection strategy for prolonged periods of circulatory arrest is still controversial. This study evaluated whether retrograde cerebral perfusion (RCP) provides adequate brain protection for prolonged periods of deep hypothermic circulatory arrest (DHCA). METHODS: From January 1997 to December 2014, 1,043 patients underwent aortic arch operations using RCP and DHCA at 18°C. The DHCA time for 993 patients was 49 minutes or less and the DHCA time for the remaining 50 patients was 50 minutes or more. Propensity matching between the two groups was performed, taking into account the main preoperative and surgical variables and all the preoperative and intraoperative neurologic risk factors. Logistic regression analysis was performed to identify independent predictors of operative death and postoperative cerebral complications. RESULTS: In the unmatched population, mortality in the 50 minutes or more vs the 49 minutes or less group was 8% vs 3.8% (p = 0.143), and the stroke rate was 2% vs 1.2% (p = 0.623). Propensity matching resulted in 48 pairs. Operative death and incidence of transient and permanent neurologic deficit were similar and not statistically significant in the matched groups for all comparisons. No difference in the incidence of other major postoperative complications was found between the two groups. Midterm survival was similar. Regression analysis showed DHCA duration was not independently associated with operative death or postoperative neurologic deficits. CONCLUSIONS: RCP is an effective adjunctive cerebral protection strategy for complex aortic arch aneurysm repair with prolonged DHCA and is not associated with increased death or neurologic complications.

Retrograde perfusion through superior vena cava reaches the brain during circulatory arrest.

BACKGROUND: The optimal technique for brain perfusion during circulatory arrest remains controversial. Concern exists that retrograde cerebral perfusion (RCP) via the superior vena cava (SVC) is unable to perfuse the brain. We evaluated whether RCP blood circulates through the brain parenchyma in humans during deep hypothermic circulatory arrest (DHCA). We hypothesized that a significant difference in the levels of S-100ß (a protein with very high neuro-sensitivity) between the blood infused in the SVC and the effluent blood returning in the left carotid artery (CA) during RCP, should be regarded as a sign of the circulation of RCP blood through the brain parenchyma. METHODS: We enrolled 10 non-consecutive patients undergoing elective arch-surgery using DHCA and RCP. Circulating S-100ß levels were measured at baseline and immediately before DHCA. During DHCA and RCP the difference in S-100ß between the SVC and the CA was evaluated after 10 minutes of arrest and immediately before resumption of the circulation. S-100ß levels were evaluated using enzyme-linked immunosorbent assay (ELISA). RESULTS: Mean DHCA duration was 22.4±7.9 minutes. Mean S-100ß level at baseline was 92.5±54.9 µg/L. After 10 minutes of DHCA the level of S-100ß in the CA was significantly higher than in the SVC (936.9±326.3 vs. 810.9±307.4 µg/L, P=0.0021). This difference was enhanced at the second DHCA sample (1113.8±334.2 vs. 920.5±340.0 µg/L, P=0.0002). There was a statistically significant correlation between the duration of DHCA and the percent difference in S-100ß level between the SVC and the CA (Pearson's correlation coefficient =0.902). CONCLUSIONS: RCP is able to perfuse the brain parenchyma in humans during DHCA.

Incomplete revascularization and long-term survival after coronary artery bypass surgery.

BACKGROUND: We sought to investigate the impact of incomplete revascularization (IR) on long-term survival after isolated coronary artery bypass grafting (CABG). The possible interaction between IR and off-pump surgery was also explored. METHODS: A total of 13,701 patients with multivessel disease undergoing CABG were included in the analysis. All patients received left internal thoracic artery (LITA) to the left anterior descending artery (LAD) territory. IR was defined as at least one diseased arterial territory (right coronary artery [RCA] and/or circumflex [CX] artery) incompletely revascularized. RESULTS: Overall, 3107 (22.7%) patients received IR. After propensity score matching, IR did not increase all-cause death in the overall group (HR 1.09; 95%CI 0.96-1.22; P=0.17). However, when both RCA and CX artery were incompletely revascularized, late survival was significantly lower (HR 2.15; 95%CI 1.57-2.93). IR was associated with a higher risk of death after off-pump (HR 1.26; 95%CI 1.05-1.49) regardless the extent of IR. After on-pump, IR significantly affected survival only when both RCA and CX artery only were incompletely revascularized (HR 2.32; 95%CI 1.27-4.22). CONCLUSIONS: The present analysis shows that in patients with LITA-LAD graft the impact of IR on survival is marginal when only one coronary territory is left ungrafted. When both the RCA and CX territory remain unrevascularized the survival rate is significantly reduced. IR after off-pump CABG is associated with significantly lower survival and affects long-term outcome even when only one coronary territory is not revascularized.

Comparison of Outcomes for Off-Pump Versus On-Pump Coronary Artery Bypass Grafting in Low-Volume and High-Volume Centers and by Low-Volume and High-Volume Surgeons.

In terms of in-hospital outcomes, controversy still remains whether off-pump coronary artery bypass grafting is superior to on-pump coronary artery bypass surgery. We investigated whether the volume of off-pump coronary artery bypass procedures by hospital and individual surgeon influences patient outcomes when compared with on-pump coronary artery bypass surgery. Discharge records from the Nationwide Inpatient Sample were retrospectively reviewed for in-hospital admissions from 2003 to 2011, including 999 hospitals in 44 states. A total of 2,094,094 patients undergoing on- and off-pump coronary artery bypass surgery were included. In patients requiring 2 or more grafts, off-pump coronary artery bypass compared with on-pump coronary artery bypass was associated with increased risk-adjusted mortality when performed in low-volume centers (<29 cases per year) (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.06 to 1.57) or by low-volume surgeons (<19 cases per year) (OR 1.26, 95% CI 1.02 to 1.56). In high-volume off-pump coronary artery bypass centers (≥164 cases per year) and surgeons (≥48 cases per year), off-pump coronary artery bypass reduced mortality compared with on-pump coronary artery bypass in cases requiring a single graft (OR 0.66, 95% CI 0.49 to 0.89 and OR 0.33, 95% CI 0.22 to 0.47, respectively) or 2 or more grafts (OR 0.82, 95% CI 0.66 to 0.99 and OR 0.63, 95% CI 0.49 to 0.81, respectively). In conclusion, the outcome of off-pump coronary artery bypass grafting procedures is dependent on volume at both the institution and the individual surgeon level. Off-pump coronary artery bypass should not be performed at low-volume centers and by low-volume surgeons.

Does a balanced transfusion ratio of plasma to packed red blood cells improve outcomes in both trauma and surgical patients? A meta-analysis of randomized controlled trials and observational studies.

BACKGROUND: The effect of high transfusion ratios of fresh frozen plasma (FFP): packed red blood cell (RBC) on mortality is still controversial. Observational evidence contradicts a recent randomized controlled trial regarding mortality benefit. This is an updated meta-analysis, including a non-trauma cohort. METHODS: Patients were grouped into high vs. low based on FFP:RBC ratio. Primary outcomes were 24-h and 30-day/in-hospital mortality. Secondary outcomes were acute respiratory distress syndrome and acute lung injury rates. Random model and leave-one-out-analyses were used. RESULTS: In 36 studies, lower ratio showed poorer 24-h and 30-day survival (p < 0.001). In trauma and non-trauma settings, a lower ratio was associated with worse 24-h and 30-day mortality (P < 0.001). A ratio of 1:1.5 provided the largest 24-h and 30-day survival benefit (p < 0.001). The ratio was not associated with ARDS or ALI. CONCLUSIONS: High FFP:RBC ratio confers survival benefits in trauma and non-trauma settings, with the highest survival benefit at 1:1.5.

New-generation stents compared with coronary bypass surgery for unprotected left main disease: A word of caution.

BACKGROUND: With the advent of bare metal stents and drug-eluting stents, percutaneous coronary intervention has emerged as an alternative to coronary artery bypass grafting surgery for unprotected left main disease. However, whether the evolution of stents technology has translated into better results after percutaneous coronary intervention remains unclear. We aimed to compare coronary artery bypass grafting with stents of different generations for left main disease by performing a Bayesian network meta-analysis of available randomized controlled trials. METHODS: All randomized controlled trials with at least 1 arm randomized to percutaneous coronary intervention with stents or coronary artery bypass grafting for left main disease were included. Bare metal stents and drug-eluting stents of first- and second-generation were compared with coronary artery bypass grafting. Poisson methods and Bayesian framework were used to compute the head-to-head incidence rate ratio and 95% credible intervals. Primary end points were the composite of death/myocardial infarction/stroke and repeat revascularization. RESULTS: Nine randomized controlled trials were included in the final analysis. Six trials compared percutaneous coronary intervention with coronary artery bypass grafting (n = 4654), and 3 trials compared different types of stents (n = 1360). Follow-up ranged from 6 months to 5 years. Second-generation drug-eluting stents (incidence rate ratio, 1.3; 95% credible interval, 1.1-1.6), but not bare metal stents (incidence rate ratio, 0.63; 95% credible interval, 0.27-1.4), and first-generation drug-eluting stents (incidence rate ratio, 0.85; 95% credible interval, 0.65-1.1) were associated with a significantly increased risk of death/myocardial infarction/stroke when compared with coronary artery bypass grafting. When compared with coronary artery bypass grafting, the highest risk of repeat revascularization was observed for bare metal stents (hazard ratio, 5.1; 95% confidence interval, 2.1-14), whereas first-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) and second-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) were comparable. CONCLUSIONS: The introduction of new-generation drug-eluting stents did not translate into better outcomes for percutaneous coronary intervention when compared with coronary artery bypass grafting.

Is Less More or Is More Less?

Although aortic hemiarch replacement without the use of deep hypothermic circulatory arrest may be feasible in experienced centers, manipulation of the aortic arch and great vessels is of concern. Additional research is necessary before widespread adoption of this technique.

Impact of preoperative pulmonary function on outcomes after open repair of descending and thoracoabdominal aortic aneurysms.

OBJECTIVE: To evaluate the impact of preoperative pulmonary function on outcomes after open repair of descending thoracic (DTA) and thoracoabdominal aortic (TAAA) aneurysms. METHODS: The outcomes of patients undergoing open repair of DTA or TAAA were analyzed in relation to the results of preoperative pulmonary function tests. Receiver operating characteristic was adopted to assess the effect of forced expiratory volume in one second (FEV1) on the incidence of mortality. Logistic regression analysis and propensity score matching were used. RESULTS: Between 1997 and 2015, 726 patients underwent open DTA or TAAA repair. Pulmonary function tests were available in 711 (97.9%). Receiver operating characteristic analysis revealed the cutoff value of FEV1 to be 50%. Propensity score matching led to 149 pairs of patients with FEV1 below and above 50% with only limited residual imbalance. In the matched population operative mortality was 11.4% and 6.0% in patients with FEV1 ≤ 50% and FEV1 ≥ 51%, respectively (P = .10). The incidence of major adverse events was 33.1% in cases with FEV1 ≤ 50% and 19.5% in those with FEV1 ≥ 51% (P = .008). FEV1 ≤ 50% was associated with a 6.99× increase in the risk of major postoperative adverse events at logistic regression analysis. CONCLUSIONS: Preoperative FEV1 < 50% is strongly predictive of increased respiratory failure, tracheostomy, and operative mortality in patients undergoing open DTA/TAAA repair. For these very high-risk patients with either extensive TAAAs or anatomy unsuitable for endovascular repair, medical therapy may offer the best long-term survival.

Contemporary prevalence, in-hospital outcomes, and prognostic determinants of triple valve surgery: National database review involving 5,234 patients.

BACKGROUND: Triple valve surgery (TVS) remains a challenging procedure with limited existing literature. We aim to evaluate the prevalence, in-hospital outcomes, and prognostic determinants of TVS in the current era. MATERIALS AND METHODS: We reviewed the Nationwide Inpatient Sample database from 2003 to 2012 and included all patients who underwent aortic valve replacement (AVR) combined with mitral valve replacement (MVR) or repair (MVRep) and tricuspid valve replacement (TVR) or repair (TVRep). Logistic regression analysis was used to identify independent predictors of in-hospital mortality and propensity score matching was adopted to compare groups receiving different operations. RESULTS: Overall, 5234 patients were included. In-hospital mortality was 13.9%. Major adverse events occurred in 42.9% of the cases (44.9%, 40.3%, 44.4% and 74.2% in the AVR + MVR + TVR, AVR + MVR + TVRep, AVR + MVRep + TVRep and AVR + MVRep + TVR groups respectively, p < 0.05 for all intergroup comparisons). In-hospital mortality in the AVR + MVR + TVR, AVR + MVR + TVRep, AVR + MVRep + TVRep and AVR + MVRep + TVR groups was 19.9%, 13.3%, 12.9% and 0% respectively (p < 0.05 for all intergroup comparisons). At regression analysis, age, reoperation, and urgent/emergent operation were independent predictors of in-hospital mortality. Patients submitted to tricuspid valve repair and mitral and tricuspid repair had a 62% and 63% mortality risk reduction (OR:0.380, CI:0.19-0.76 p = 0.006 and OR:0.37, CI:0.18-0.78 p = 0.009 respectively). In the propensity matched comparisons, in-hospital mortality was statistically similar (p = 0.08 for AVR + MVR + TVR vs. AVR + MVR + TVRep comparison and p = 0.06 for AVR + MVR + TVR vs. AVR + MVRep + TVRep comparison). CONCLUSIONS: TVS is associated with significant in-hospital mortality and morbidity. The use of valve repair strategies for the mitral and tricuspid valves can positively impact postoperative outcomes.

Serendipity and innovation: history and evolution of transthoracic echocardiography.

The history of echocardiography is sprinkled with many interesting episodes and anecdotes showing that devoting your life to the pursuit of one goal is praiseworthy, and that at the same time, a little luck goes a long way. Transthoracic echocardiography (TTE) has led to dramatic improvements in cardiovascular medicine, and is now the most widely used diagnostic cardiac test after electrocardiography (ECG). The present review pays tribute to the pioneering efforts of those who believed in this innovative technology despite mounted skepticism and briefly describes the evolution of TTE from its early days to the most recent developments.

Techniques for intraoperative graft assessment in coronary artery bypass surgery.

Early graft patency is a major determinant of morbidity and mortality following coronary artery bypass surgery. Long-term graft failure is caused by intimal hyperplasia and atherosclerosis, while early failure, especially in the first year, has been attributed, in part, to surgical error. The need for intraoperative graft evaluation is paramount to determine need for revision and ensure future functioning grafts. Transit time flowmetry (TTFM) is the most commonly used intraoperative modality, however, only about 20% of cardiac surgeons in North America use TTFM. When combined with high resolution epicardial ultrasonography, TTFM provides high diagnostic yield. Fluorescence imaging can provide excellent visualization of the coronary and graft vasculature; however, data on this subject is limited. We herein examine the literature and discuss the available techniques for graft assessment along with their limitations.

Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit‡.

OBJECTIVES: Valve-sparing operations and root replacement with a biologic composite conduit are viable options in aortic root aneurysm. This study was conceived to compare the early and mid-term results of these 2 procedures. METHODS: From September 2002 to November 2015, 749 consecutive patients underwent either a valve-sparing operation or a root replacement with a biologic composite conduit at 2 institutions. Propensity score matching was used to compare similar cohorts of patients in the overall population and in the ≤ 55 and ≥ 65-year age groups. RESULTS: Overall operative mortality was 0.4%, mean age 57.4 ± 14.3 years, 84.6% were male. Individuals in the biologic composite conduit group were older and had worse preoperative risk profiles [chronic pulmonary disease (5.5% vs 0.9%; P = 0.001), diabetes (6.4% vs 1.5%; P = 0.001) and NYHA > 2 (25.2% vs 5.2%; P < 0.001)]. Mean follow-up was 27.5 ± 28.4 months. In the unmatched population, there was no difference in in-hospital deaths (0 in the valve-sparing versus 3 in the biologic composite conduit group; P = 0.12). These findings were confirmed in the propensity-matched populations. During follow-up, more patients in the biologic composite conduit group underwent reoperation on the aortic valve (2.6% vs 1.5%; P = 0.026) resulting in a freedom from reoperation of 97.4% vs 98.5%, respectively. Separate analysis for patients stratified by age revealed no difference in outcomes. CONCLUSIONS: In case of aortic root aneurysm, both valve-sparing operations and root replacement with a biologic composite conduit provide excellent outcomes. However, at mid-term follow-up the use of biologic composite conduit is associated with a higher risk of reoperation.