Expert Opinions on the Debate of Pericardial Reconstruction in Cardiovascular Surgery: To Close or Not to Close?

BACKGROUND: As of 2019, pericardial closure was performed in only a small portion of the over 320,000 cardiac surgeries performed annually. However, evidence regarding the benefits of pericardial closure or reconstruction has been accruing, particularly with the publication of the RECON study in 2019.  Methods: This group of authors convened to try to arrive at consensus expert opinion regarding pericardial reconstruction. Structured topic questions initially were used to stimulate discussion. Subsequently, a survey of proposed expert opinion statements was conducted among the authors. Based on that survey, consensus expert opinion statements and recommendations were compiled. RESULTS: The expert opinions encompass various topics relating to pericardial reconstruction, including definitions, benefits/risks, and technique. Observed benefits include reductions in: (1) adhesions; (2) postoperative pericardial effusion, atrial fibrillation, and bleeding; and (3) readmissions and length of hospital stay. Expert opinion recommendations regarding surgical technique are compiled into a single chart. Complete pericardial reconstruction should be performed, using native pericardial tissue if available and viable; if not feasible, a patch may be used. Patches that stimulate the formation of site-specific tissue in situ (such as natural extracellular matrix) may have additional benefits (including bioregenerative properties and lack of inflammatory response). Closure should be taut, but tension-free. Adequate drainage of the closed pericardium must be ensured. CONCLUSIONS: Based on available data and collective surgical experience, we endorse pericardial reconstruction as standard approach in appropriately selected patients. We also endorse adoption of standardized pericardial reconstruction techniques to optimize patient outcomes and improve evidence quality in future studies.

Alternative Implantation Technique for Rapid Deployment Valve.

We present a simpler and faster way of implanting the Edwards Intuity Elite rapid deployment valve system. Annular sizing and guiding suture placement are performed in the usual manner. After the valve is parachuted down to the annulus, the balloon catheter is detached and a vent catheter is placed through the center hole to maximize exposure of the valve. The guiding sutures are tied down using an automated suture fastening device instead of securing snares. Visualization of the tip of the suture fastener on the annulus ensures proper valve seating. The sealing frame is ballooned, and the valve is deployed.

Pericardial closure with extracellular matrix scaffold following cardiac surgery associated with a reduction of postoperative complications and 30-day hospital readmissions.

BACKGROUND: A prospective, multi-center study (RECON) was conducted to evaluate the clinical outcomes of pericardial closure using a decellularized extracellular matrix (ECM) graft derived from porcine small intestinal submucosa. METHODS: Patients indicated for open cardiac surgery with pericardial closure using ECM were eligible for the RECON study cohort. Postoperative complications and readmission of the RECON patients were compared to the patient cohort in the Nationwide Readmissions Database (NRD). Inverse probability of treatment weighting was used to control the differences in patient demographics, comorbidities, and risk factors. RESULTS: A total of 1420 patients at 42 centers were enrolled, including 923 coronary artery bypass grafting (CABG) surgeries and 436 valve surgeries. Significantly fewer valve surgery patients in the RECON cohort experienced pleural effusion (3.1% vs. 13.0%; p < 0.05) and pericardial effusion (1.5% vs. 2.6%; p < 0.05) than in the NRD cohort. CABG patients in the RECON cohort were less likely to suffer bleeding (1.2% vs. 2.9%; p < 0.05) and pericardial effusion (0.2% vs. 2.2%, p < 0.05) than those in the NRD cohort. The 30-day all-cause hospital readmission rate was significantly lower among RECON patients than NRD patients following both valve surgery (HR: 0.34; p < 0.05) and CABG surgery (HR: 0.42; p < 0.05). In the RECON study, 14.4% of CABG patients and 27.0% of valve patients had postoperative atrial fibrillation as compared to previously reported risks, which generally ranges from 20 to 30% after CABG and from 35 to 50% after valve surgery. CONCLUSIONS: Pericardial closure with ECM following cardiac surgery is associated with a reduction in the proportion of patients with pleural effusion, pericardial effusion, and 30-day readmission compared to a nationwide database. TRIAL REGISTRATION: NCT02073331 , Registered on February 27, 2014.

Institutional variability of intraoperative red blood cell utilization in coronary artery bypass graft surgery.

The variability in frequency of allogeneic blood transfusion during coronary artery bypass surgery (CABG) is a concern. Evidence-based guidelines support minimizing the use of blood during open heart surgery. The Hospital Clinical Services Group quality indicator database was queried for intraoperative red blood cell (RBC) transfusions in 17 252 isolated CABG surgery cases during 2007. Institutional variability was observed in the frequency of intraoperative RBC transfusion rates, which ranged from 0% to 85.7%. The institution mean RBC transfusion rate was 40.8%. Regional geographic and cardiac program size variations were observed in RBC transfusion rates and volume with significant variation. Notable institutional variability persists with respect to intraoperative RBC transfusion in isolated CABG surgery despite clear evidence and guidelines to support techniques to minimize RBC transfusion. Such results support the hypothesis that incorporating evidence-based transfusion-related practices in open heart surgery are not uniformly adopted.