In Situ Composition of Valved Conduit for Complex Reoperative Aortic Root Replacement.

We describe a novel technique, in situ composition of a valved conduit, for complex reoperative aortic root replacement. The absence of a rigid stented aortic valve prosthesis facilitates left ventricular outflow tract (LVOT) reconstruction and coronary reimplantation. First, a Dacron graft, inverted and inserted into the LVOT, is sewn to the LVOT, followed by coronary button reimplantation and then prosthetic valve implantation. For cases that require LVOT reconstruction, the graft below the prosthetic valve serves as a circumferential patch. Our technique requires only surgical materials that are readily available without the need for a specialized skillset.

Prospective Comparison of a Percutaneous Ventricular Assist Device and Venoarterial Extracorporeal Membrane Oxygenation for Patients With Cardiogenic Shock Following Acute Myocardial Infarction.

Background Cardiogenic shock ( CS ) following acute myocardial infarction ( AMI ) portends a poor prognosis. Both venoarterial extracorporeal membrane oxygenation ( VA - ECMO ) and a percutaneous ventricular assist device ( pVAD ) provide hemodynamic support for patients with CS, but little is known about the best device for this population. We sought to compare outcomes of AMI patients treated with these devices. Methods and Results Consecutive patients with CS following AMI from April 2015 to March 2017 were enrolled prospectively if they received either device for AMI -related CS . If patients received both devices, they were analyzed according to the first used. The primary outcome was all-cause mortality. In total, 51 patients received VA - ECMO or pVAD following AMI ; 20 received VA - ECMO, and 31 received pVAD . The mean age was 62.1±10.1 years, and 39 (76.5%) were men. Twenty-four (47.1%) patients were ultimately supported by both devices simultaneously (20 pVAD -first, 4 VA - ECMO -first). Patients treated with pVAD or VA - ECMO were similar in baseline characteristics at initial device insertion except that the latter were on more vasopressors and were more likely to have an intra-aortic balloon pump. Seventeen (33.3%) had recent cardiopulmonary resuscitation, mean lactate was 4.86±3.96 mmol/L, and mean cardiac index was 1.70±0.42 L/min per m2. Of the 28 (54.9%) patients surviving to discharge, 11 had received VA - ECMO first and 17 had pVAD first ( P=0.99). Survival at 1 and 2 years did not differ significantly between device groups ( P=0.42). Conclusions Following AMI -related CS , pVAD - and VA - ECMO -treated patients had similar outcomes. The use of both devices simultaneously was common, with almost half of patients in persistent CS after first device deployment.

Reversibility of chronic kidney disease and outcomes following aortic valve replacement†.

OBJECTIVES: Chronic kidney disease (CKD) is prevalent in patients undergoing aortic valve replacement (AVR). We sought to evaluate the impact of AVR on estimated glomerular filtration rate (eGFR) levels and determine the impact of reversibility of CKD on postoperative outcomes. METHODS: We retrospectively reviewed 2169 patients who underwent isolated AVR between 2000 and 2012. eGFR was calculated using the CKD-EPI formula. Based on preoperative eGFR, patients were divided into three groups: NoCKD (eGFR >60, n = 1417), ModCKD (eGFR = 30-60, n = 619) and SevCKD (eGFR = 15-30, n = 86). End-stage renal disease patients (eGFR <15 and/or dialysis, n = 47) were excluded from the study. RESULTS: Before AVR, eGFR in the NoCKD, ModCKD and SevCKD groups was 81.3 ± 14.2, 48.9 ± 8.10 and 25.3 ± 4.12 ml/min/1.73 m(2), respectively. NoCKD patients showed a decline in eGFR during the first month postoperatively; thereafter, eGFR remained stable over 1 year. ModCKD and SevCKD patients demonstrated an initial improvement in eGFR, which peaked at 1 week postoperatively. In ModCKD, eGFR stabilized at a slightly lower level thereafter out to 1-year follow-up. In SevCKD, eGFR declined slightly out to 6 months postoperatively. Regardlessly, eGFR in ModCKD at 1 year and in SevCKD at 6 months postoperatively demonstrated sustained improvement over baseline eGFR. Reversibility of CKD was associated with a better long-term survival in the ModCKD group (P < 0.001) and short-term survival in the SevCKD group (P = 0.018). CONCLUSIONS: AVR confers a marked initial improvement in eGFR, which is sustained in patients with ModCKD and SevCKD, and is associated with a better survival. The reversible nature of CKD in certain patients warrants careful consideration during preoperative risk scoring and stratification.