Marital status impact on the outcomes of patients admitted for acute decompensation of heart failure: A retrospective, single-center, analysis.

BACKGROUND: Conflicting evidence exists regarding the association between marital status and outcomes in patients with heart failure (HF). Further, it is not clear whether type of unmarried status (never married, divorced, or widowed) disparities exist in this context. HYPOTHESIS: We hypothesized that marital status will be associated with better outcomes in patients with HF. METHODS: This single-center retrospective study utilized a cohort of 7457 patients admitted with acute decompensated HF (ADHF) between 2007 and 2017. We compared baseline characteristics, clinical indices, and outcomes of these patients grouped by their marital status. Cox regression analysis was used to explore the independency of the association between marital status and long-term outcomes. RESULTS: Married patients accounted for 52% of the population while 37%, 9%, and 2% were widowed, divorced, and never married, respectively. Unmarried patients were older (79.8 ± 11.5 vs. 74.8 ± 11.1 years; p < 0.001), more frequently women (71.4% vs. 33.2%; p < 0.001), and less likely to have traditional cardiovascular comorbidities. Compared with married patients, all-cause mortality incidence was higher in unmarried patients at 30 days (14.7% vs. 11.1%, p < 0.001), 1 year, and 5 years (72.9% vs. 68.4%, p < 0.001). Nonadjusted Kaplan-Meier estimates for 5-year all-cause mortality by sex, demonstrated the best prognosis for married women, and by marital status in unmarried patients, the best prognosis was demonstrated in divorced patients while the worst was recorded in widowed patients. After adjustment for covariates, marital status was not found to be independently associated with ADHF outcomes. CONCLUSIONS: Marital status is not independently associated with outcomes of patients admitted for ADHF. Efforts for outcomes improvement should focus on other, more traditional risk factors.

All-cause Readmission after Transcatheter Aortic Valve Replacement in a Community Hospital - Long Term Follow-up.

BACKGROUND: Post-procedure readmissions are associated with lower quality of life and increased economic burden. The study aimed to identify predictors for long-term all-cause readmissions in patients who underwent transcatheter aortic valve replacement (TAVR) in a community hospital. METHODS: A Historical cohort study of all adults who underwent TAVR at Cape-Cod hospital between June 2015 and December 2017 was performed and data on readmissions was collected up-to May 2020 (median follow up of 3.3 years). Pre-procedure, procedure and in-hospital post-procedure parameters were collected. Readmission rate was evaluated, and univariate and multivariable analyses were applied to identify predictors for readmission. RESULTS: The study included 262 patients (mean age 83.7±7.9 years, 59.9% males). The median Society of Thoracic Surgeons (STS) probability of mortality (PROM) score was 4.9 (IQR, 3.1-7.9). Overall, 120 patients were readmitted. Ten percent were readmitted within 1-month, 20.8% within 3-months, 32.0% within 6-months and 44.5% within 1-year. New readmissions after 1-year were rare. STS PROM 5% or above (HR 1.50, p = 0.039), pre-procedure anemia (HR 1.63, p = 0.034), severely decreased pre-procedure renal function (HR 1.93, p = 0.040) and procedural complication (HR 1.65, p = 0.013) were independent predictors for all-cause readmission. CONCLUSIONS: Elevated procedural risk, anemia, renal dysfunction and procedural complication are important predictors for readmission. Pre-procedure and ongoing treatment of the patient's background diseases and completion of treatment for complications prior to discharge may contribute to a reduction in the rate of readmissions.

Myocardial preservation methods in isolated minimal invasive mitral valve surgery: Society of Thoracic Surgeons (STS) database outcomes.

OBJECTIVE: Minimal invasive mitral valve surgery (MIMVS) has become a commonly used approach for mitral valve surgery. Several techniques of myocardial preservation were described in patients undergoing MIMVS. We aim to evaluate preservation technique and short term outcomes. METHODS: A retrospective analysis of patients who underwent isolated MIMVS and were included in the Society of Thoracic Surgeons (STS) database. RESULTS: The final cohort included 4976 patients. Mean age was 63.1 years (SD, 12.5) and 42.6% were females. Antegrade delivery method (71.3% of the patients) was the most common, follow by antergrade/retrograde (19.9%). Blood, crystalloid solution, and combination of blood-crystalloid were used in 62.4%, 13.2%, and 13.7%, respectively. In multivariate analysis, cardioplegia technique was associated with mortality (P = .011), pleural effusion (P = .045), and length of ICU stay (P < .001). Antegrade-crystalloid (OR, 3.37; 95%CI, 1.70-6.68) and antegrade/retrograde-blood/crystalloid (OR, 3.28; 95%CI, 1.15-9.38) were associated with increased risk for mortality compared with antegrade-blood cardioplegia. Data on postoperative ejection fraction (EF), CPK-MB, and Troponin was available only in 30%, 9%, and 5% of the patients, respectively, and were not included in the analysis. CONCLUSIONS: Ante-grade-blood was the most common preservation technique in MIMVS. Ante-grade-crystalloid and ante-grade/retrograde-blood/crystalloid are associated with increased risk for mortality. The results suggest that using crystalloid solutions for cardioplegia should be carefully considered. The STS database as a source for MIMVS outcome analysis is lacking, both in detailed specification of different surgical technique aspects, and in actual data collection of already existing categories.

Surgical versus trans-catheter aortic valve replacement (SAVR vs TAVR) in patients with aortic stenosis: Experience in a community hospital.

Trans-catheter aortic valve replacement (TAVR) has become an alternative to surgical aortic valve replacement (SAVR) in high and intermediate risk patients with aortic stenosis. TAVR programs are spreading from large referral centers and being established in community based institutions. The purpose of this study was to compare the outcomes of TAVR to those of SAVR in a community hospital.A historical cohort study of patients with aortic stenosis and pre-post procedure echocardiography data who underwent SAVR or TAVR in Cape Cod Hospital between January 2014 and December 2016. Patient characteristics and procedure outcomes were compared between the two procedures.The study included 230 patients, of them 111 underwent SAVR and 119 underwent TAVR. None of the patients died during the 30 days after the procedure. TAVR patients had higher rates of postoperative mild+ aortic regurgitation (AR) (29.4% vs 12.6%, P = .002), postoperative atrial ventricular blocks (11.8% vs 0.9%, P = .001), and more often need an implantation of pacemaker (16.8% vs 0.9%, P < .001). Postoperative mean gradient of SAVR patients was higher (median 14 vs 11 mm Hg, P = .001) and atrial fibrillation postoperatively was more frequent (18.9% vs 2.5%, P < .001). Length of stay after procedure was shorter in TAVR patients (median 2 vs 4 days, P < .001).After controlling for confounders, the use of TAVR was associated with an increased risk for postoperative pacemaker implantation (OR = 16.3, 95%CI 1.91-138.7, P = .011), lower mean gradient (-4.327, 95%CI -7.68 to -0.98, P = .011), and lower risk for atrial fibrillation (OR = 0.11, 95%CI 0.03-0.38, P = .001), but not with postoperative AR (OR = 0.84, 95%CI 0.22-3.13, P = .789).In conclusion, short-term mortality was not reported in SAVR or TAVR patients. However, TAVR was associated with an increased risk for postoperative pacemaker implantation but with a lower risk for atrial fibrillation. Aortic valves implanted through a trans-catheter approach are also associated with a better hemodynamic performance.

Comparison of heart transplant outcomes between recipients with pulsatile- vs continuous-flow LVAD.

OBJECTIVE: Continuous-flow (CF) left ventricular assist devices (LVADs) have replaced pulsatile flow (PF) LVADs irrespective of concerns from the physiologic changes/morbidity secondary to lack of pulsatility. Data comparing posttransplant outcomes in patients with CF vs PF LVADs are limited and conflicting. We used the Organ Procurement and Transplant Network database to compare posttransplant outcomes between CF and PF LVAD patients. METHODS: From 1 January 2005 to 31 December 2011, 3449 adult patients underwent primary heart alone transplantation. The cohort was restricted to 2741 recipients with LVAD at the time of transplant and divided into two groups: PF (Heartmate XVE) (n = 705) and CF (Heartmate II, HeartWare HVAD, and Jarvik 2000) (n = 2036). Endpoints were 30-day freedom from graft failure, 1-, and 5-year patient survival. Propensity score matching identified 705 pairs for adjusted comparisons. RESULTS: Among propensity-matched patients, 30-day freedom from graft failure after heart transplantation (PF = 94.8% vs CF = 95.2%, P > .7), and 1-, and 5-year patient survival (PF; 87.5% vs CF; 88.9%, P = .4, and PF;75.7% vs CF;77.5%, P = .3) were not different. CONCLUSION: Survival and freedom from graft failure after heart transplantation is similar between CF and PF LVADs. These findings are relevant as the use of CF devices increases despite physiologic changes related to the absence of pulsatility.

The epidemiology of coronary artery bypass surgery in a community hospital: A comparison between 2 periods.

During the last decades, the increased number of percutaneous interventions procedures causes a significant change in the profile of patients referred to coronary artery bypass grafting (CABG). We aimed to study changes in patients' characteristics and procedural outcomes of patients referred to CABG in a community hospital during the first 15 years of the millennium.A historical cohort study of all patients who underwent CABG in Cape Cod Hospital was performed. The period was divided into 2 sub-periods, 2000 to 2008 and 2009 to 2014. Patients' characteristics and procedure outcomes were compared. Data on age, sex, comorbidities, Society of Thoracic Surgery risk scores and surgical adverse outcomes (stroke, coma, and 30-days mortality) were collected.During the study period, 1108 patients underwent CABG; 612 were operated before 2009 and 496 after. Age and sex were similar in the 2 periods. The patients in the later period presented lower risk for mortality and stroke (P <.001). Diabetes (DM) was more common in the later period (P <.001) while peripheral vascular disease (PVD) (P <.001) and left main disease (LM) (P = .017) were more common in the earlier period. Mortality rates were similar between the 2 periods. Post-operative stroke (1.8%) and coma (0.8%) were presented only in the later period. In conclusion, a significant change in CABG patients' characteristics was observed.In conclusion, patients in the later period had lower risk score and were more likely to present with DM and less with PVD and LM. Despite the lower risk, the mortality rate was similar.

Off-Pump Versus On-Pump Coronary Artery Bypass Grafting-A Systematic Review and Analysis of Clinical Outcomes.

Surgical coronary artery bypass grafting (CABG) is the standard of care for revascularization of left main or three-vessel coronary artery disease. The off-pump coronary artery bypass graft (OPCAB) procedure avoids the use of cardiopulmonary bypass. Theoretically, OPCAB may improve long-term outcomes by reducing the rates of perioperative myocardial injury, stroke, neurocognitive impairment, and cardiac-related mortality. Several high-quality clinical trials have been conducted since OPCAB became popular in the 1990s and have demonstrated no benefit of OPCAB over traditional CABG with respect to these outcomes despite favorable short-term reductions in transfusion requirements and other postoperative complications. Ultimately, OPCAB is associated with less effective myocardial revascularization and does not entirely prevent complications traditionally associated with cardiopulmonary bypass. This article reviews major high-quality trials of OPCAB versus traditional CABG with respect to both short- and long-term clinical outcomes.

Trans-catheter aortic valve replacement program in a community hospital - Comparison with US national data.

Symptomatic aortic stenosis remains a surgical disease, with aortic valve replacement resulting in symptom reduction and improvement in survival. For patients who are deemed a higher surgical risk, Transcatheter aortic-valve replacement (TAVR) is a viable, less invasive and increasingly common alternative. The study compares early outcomes in patients treated within one year of the commencement of TAVR program in a community hospital against outcomes of TAVR patients from nationwide reported data (Society of Thoracic Surgeons/ American College of Cardiology TVT registry). Preoperative characteristics and standardized procedural outcomes of all patients who underwent TAVR in Cape Cod Hospital between June 2015 and May 2016 (n = 62, CCH group) were compared using standardized data format to those of TAVR patients operated during the same time period in other centers within the United States participating in the STS/ACC TVT Registry (n = 24,497, USA group). Most preoperative patient characteristics were similar between groups. However, CCH patients were older (age≥80 years: 77.4% versus 64.3%, p = 0.032) and more likely to be non-elective cases (37.1% versus 9.7%, p<0.001). All 62 TAVR procedures in CCH were performed in the catheterization laboratory unlike most (89.7%) of the procedures in the USA group that were performed in hybrid rooms. A larger proportion of patients in the USA registry underwent TAVR under general anesthesia (78.2% vs.37.1%, P<0.001). Early aortic valve re- intervention rate was 0/62 (0%) in the CCH group VS. 74/ 24,497 (0.3%) in the USA group. In hospital mortality, which was defined as death of any cause during thirty days from date of operation, (CCH: 0% vs. USA: 2.5%, p = 0.410) and occurrence of early adverse events (including postoperative para-valvular leaks, conduction defects requiring pacemakers, neurologic and renal complications) were similar in the two groups. The study concludes that with specific team training and co-ordination, and with active support of experienced personnel, high risk patients with severe aortic valve stenosis can be managed safely with a TAVR procedure in a community hospital.

Automated fastener (Core-Knot) versus manually tied knots in patients undergoing aortic valve replacement: Impact on cross-clamp time and short-term echocardiographic results.

The Core-Knot device is an automatic fastener used mainly in minimally invasive heart valve surgery procedures, to facilitate knot tying. The purpose of this report is to compare ischemic time and outcomes of surgical aortic valve replacements (SAVRs) utilizing the Core-Knot device compared with manually tied knots.Between January, 2014 and December, 2016, 119 patients underwent SAVR in Cape Cod Hospital. We compared patient's characteristics, cross-clamp time, and outcomes of 75 patients who underwent SAVR using Core-Knot to those of 44 operated using manually tied knots.Patient characteristics were similar between groups. Patients in the Core-Knot group had higher preoperative aortic valve area and higher ejection fraction. The use of Core-Knot was associated with reduced aortic cross-clamp time (median 70 vs 84 minutes; P < .001). Patients undergoing SAVR using Core-Knot were less likely to have postoperative aortic regurgitation (P < .001). Early mortality, and also the rates of early adverse events (including all cardiac, neurologic, and renal complications), and the immediate postprocedure echo findings were similar in the 2 groups. In multivariate analysis, the use of Core-Knot was associated with reduced postoperative mean gradient across the aortic valve and reduced occurrence of postoperative aortic regurgitation. Older age and larger valve size were other predictors of reduced postoperative mean gradients.The use of an automatic fastener (Core-Knot) in surgical aortic valve replacement cases reduce aortic cross-clamp time and help eliminate postoperative paravalvular aortic regurgitation.

Adverse Cerebral Outcomes after Coronary Artery Bypass Surgery-More Than a Decade of Experience in a Single Center.

BACKGROUND: Nonfatal strokes, transient ischemic attacks (TIAs), and reversible ischemic neurological deficits (RIND) after elective coronary artery bypass grafting (CABG) are devastating clinical problems. The anesthesiologist, surgical and intensive care teams in a community hospital adopted a strategy developed in an effort to minimize these adverse outcome events.The purpose of this study is to determine the incidence of and predictors for perioperative adverse neurologic events. METHODS: A historical cohort study of 1,108 consecutive CABG patients operated between 2002 and 2014. Outcomes were defined as (1) a new neurologic damage (a new stroke, TIA, or RIND) and (2) a new neurologic damage or 30 days mortality. RESULTS: Adverse cerebral outcomes occurred in 16 patients (1.4 percent). Nine patients had postoperative stroke, six suffered TIAs, and one had postoperative RIND.In multivariate analysis, older age (OR 1.07, 95% CI 1.01-1.14), congestive heart failure (OR 3.57, 95% CI 1.22-10.49) and prior stroke (OR 6.27, 95% CI 1.78-22.03) were significantly associated with increased risk of new neurologic damage. These parameters were also significantly associated with increased risk of the combined outcome (new neurologic damage/mortality). CONCLUSIONS: A low incidence rate of adverse cerebral outcomes after CABG in community hospital can be achieved with the use of the suggested surgical intensive care, and anesthetic strategy. Advanced age, congestive heart failure, and prior stroke are associated with adverse outcomes.

Coronary Endarterectomy or Patch Angioplasty for Diffuse Left Anterior Descending Artery Disease.

BACKGROUND: Coronary endarterectomy and patch angioplasty for the left anterior descending (LAD) artery have been shown to be effective adjunct techniques to surgical revascularization for severe coronary lesions. The objective of this study is to review the short- and long-term results of these two methods in our institution. METHODS: We retrospectively reviewed 166 consecutive patients who underwent internal thoracic artery grafting to the LAD, with either adjunct endarterectomy (95 patients) or patch angioplasty (71 patients) between 2002 and 2014. We compared the early and late outcomes between groups. RESULTS: The endarterectomy patients were older than the patch angioplasty patients (71 vs. 67 years, p = 0.007) and had lower rates of recent myocardial infarction (25% vs. 45%, respectively, p = 0.008). Median pulmonary bypass times and aortic cross clamp times were significantly longer in the endarterectomy group compared with the patch angioplasty group by 47 minutes (p < 0.001) and 42 minutes (p < 0.001), respectively. Median follow-up time was 6.9 years. No significant differences in operative mortality, perioperative myocardial infarction, and long-term survival were found. Freedom from percutaneous coronary intervention at 1 and 5 years was significantly higher in the endarterectomy group compared with the patch angioplasty group (p = 0.002). CONCLUSIONS: Endarterectomy and patch angioplasty are comparable methods to reach complete revascularization for highly selected patients with diffuse atherosclerotic disease in the LAD. Compared with patch angioplasty, complete extraction of the atherosclerotic plaque with an endarterectomy leads to similar short-term outcomes and long-term survival while significantly reducing the need for further interventions in the future.

Should Bilateral Internal Thoracic Artery Grafting Be Used in Patients After Recent Myocardial Infarction?

BACKGROUND: Bilateral internal thoracic artery grafting (BITA) is associated with improved survival. However, surgeons do not commonly use BITA in patients after myocardial infarction (MI) because survival is good with single internal thoracic artery grafting (SITA). We aimed to compare the outcomes of BITA with those of SITA and other approaches in patients with multivessel disease after recent MI. METHODS AND RESULTS: In total, 938 patients with recent MI (<3 months) who underwent BITA between 1996 and 2011 were compared with 682 who underwent SITA. SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, chronic renal failure, peripheral vascular disease), to be female, and to have had a previous MI. Acute MI and 3-vessel disease were more prevalent in the BITA group. Operative mortality of BITA patients was lower (3.0% versus 5.8%, P=0.01), and sternal infections and strokes were similar. Median follow-up was 15.21 years (range: 0-21.25 years). Survival of BITA patients was better (70.3% versus 52.5%, P<0.001). Propensity score matching was used to account for differences in preoperative characteristics between groups. Overall, 551 matched pairs had similar preoperative characteristics. BITA was a predictor of better survival in the matched groups (hazard ratio: 0.679; P=0.002; Cox model). Adjusted survival of emergency BITA and SITA patients was similar (hazard ratio: 0.883; P=0.447); however, in the nonemergency group, BITA was a predictor of better survival (hazard ratio: 0.790; P=0.009; Cox model). CONCLUSIONS: This study suggests that survival is better with BITA compared with SITA in nonemergency cases after recent MI, with proper patient selection.

Transcatheter Aortic Valve Replacement via Left Anterior Thoracotomy in a Patient With Severe Pectus Excavatum.

With the development of the transcatheter aortic valve replacement, innovative approaches can be geared to atypical and challenging cases. We describe a case of transcatheter aortic valve replacement via a left anterior thoracotomy in a patient with pectus excavatum and unusual intrathoracic anatomy where surgical and traditional transcatheter aortic valve replacement approaches were deemed inapplicable.

The Use of Lidocaine Containing Cardioplegia in Surgery for Adult Acquired Heart Disease.

BACKGROUND: Del Nido cardioplegia, a crystalloid-based solution with lidocaine as a key element, is given as a single dose and has been used successfully in congenital cardiac surgery. HYPOTHESIS: We retrospectively compared a lidocaine containing "modified del Nido" solution with our standard whole blood cardioplegia to investigate its safety and efficacy in adult cardiac surgery. METHODS: From June 1, 2013 to December 30, 2013, we used a single dose of lidocaine containing cardioplegia (LC group) in 92 consecutive operations. Propensity matching analysis was undertaken to compare the outcomes of such patients with those who underwent their surgery by the same surgeon using standard whole blood cardioplegia (WB group), n = 396. Propensity score matching yielded 79 pairs of patients. RESULTS: After propensity matching, LC and WB groups were similar in baseline operative characteristics including cross-clamp time (LC: 65 minutes [range 54 to 89] vs. WB: 70 minutes [54 to 86], p = 0.993). Postoperative outcomes were similar including inotropic requirements (30.4% [24/72] vs. 25.3% [20/72], p < 0.60), median ventilation time (4.7 hours vs. 5.3, p < 0.74) and median length of stay was seven days for both groups (p < 0.82). Despite higher median postoperative, 24-hour CK-MB levels LC group (LC:22.3 ng/ml, range [15.6 to 40.3] vs. WB:18.4 ng/ml [13.9 to 28.2], p = 0.040), operative and one-year mortality were comparable among study groups (both p > 0.798). CONCLUSIONS: Lidocaine containing cardioplegia appears to be safe in adults undergoing cardiac procedure when administered for the first 60 minutes of aortic cross clamping. Higher CK-MB levels did not translate into adverse clinical outcomes.

The impact of a minimally invasive approach on reoperative aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: The advantages of minimally invasive aortic valve replacement (AVR) are well documented, but whether the benefits extend to subsequent reoperative aortic valve surgery and beyond is unknown. The study aim was to compare in-hospital outcomes and long-term survival following reoperative AVR between patients who had previous undergone either minimally invasive AVR (mini-AVR) or full sternotomy AVR (sAVR). METHODS: All reoperative, isolated AVRs performed between July 1997 and September 2013 at the authors' institution, with or without non-complex aortic surgery, were identified. Patients were excluded if AVR was not isolated, had occurred prior to July 1997, or if the initial AVR was performed before the patient was aged 18 years. All reoperations were performed through a full sternotomy. The main outcomes of interest were operative results and long-term survival. RESULTS: A total of 101 patients was identified, of which 34 had undergone previous mini-AVR and 67 previous sAVR. The time from the previous AVR was similar in both groups (median 7.6 years overall). Of previous valve implants, 57 were bioprostheses and 44 mechanical; structural valve degeneration was the most common indication for surgery (43/101). Mini-AVR and sAVR patients did not differ significantly with regards to patient demographics and preoperative risk factors. A strong trend towards shorter skin-to-skin operative times was observed for mini-AVR (330 min versus 356 min; p = 0.053). Postoperatively, mini-AVR patients had a shorter ventilation time (5.7 h versus 8.4 h; p = 0.005), intensive care unit stay (37 h versus 63 h; p ≤ 0.001) and hospital length of stay (6.5 days versus 8.0 days; p = 0.038). There was one operative mortality in the sAVR, and none in the mini-AVR group. Mid-term survival at one and five years for mini-AVR was 100% (95% CI 100-100) and 100% (95% CI 100-100), and for sAVR was 93.9% (95% CI 88.2-99.7) and 85.0% (95% CI 75.1-94.9), respectively (p = 0.041). CONCLUSION: Mini-AVR confers benefits during subsequent reoperative AVR, with shorter hospital stays and improved long-term survival. These findings suggest that mini-AVR should be considered for patients at risk for aortic valve reoperation, and describes a previously unreported advantage of this well-established technique.

Transjugular approach in valve-in-valve transcatheter mitral valve replacement: direct route to the valve.

With the recent emergence of transcatheter valve replacement, high-risk cases of structural valve deterioration after mitral bioprosthesis can be treated with valve-in-valve transcatheter mitral valve replacement (TMVR). The transapical approach has become the principal access for TMVR, but we report an alternative direct access for TMVR--transjugular transseptal route--in an 81-year-old woman with a degenerated mitral bioprosthesis.

Left thoracoscopic sympathectomy for cardiac denervation in patients with life-threatening ventricular arrhythmias.

BACKGROUND: We reported the outcomes of a single-institution experience using video-assisted thoracoscopic left cardiac sympathetic denervation as an adjunctive therapeutic technique in pediatric and young adult patients with life-threatening ventricular arrhythmias. METHODS: We conducted a retrospective clinical review of all patients who underwent left cardiac sympathetic denervation by means of video-assisted thoracoscopic surgery at our institution. From August 2000 to December 2011, 24 patients (13 with long QT syndrome, 9 with catecholaminergic polymorphic ventricular tachycardia, and 2 with idiopathic ventricular tachycardia) were identified from the cardiology database and surgical records. RESULTS: There were no intraoperative complications. The median postoperative length of stay was 2 days (range, 1-32 days). There were no major perioperative complications. Longer-term follow-up was available in 22 of 24 patients at a median follow-up of 28 months (range, 4-131 months). Sixteen (73%) of the 22 patients experienced a marked reduction in their arrhythmia burden, with 12 (55%) becoming completely arrhythmia free after sympathectomy. Six (27%) of the patients were nonresponsive to treatment; each had persistent symptoms at follow-up. CONCLUSIONS: Video-assisted thoracoscopic left cardiac sympathetic denervation can be safely and effectively performed in most patients with life-threatening ventricular arrhythmias. This minimally invasive procedure is a promising adjunctive therapeutic option that achieves a beneficial response in most symptomatic patients. These results support the inclusion of thoracoscopic cardiac sympathetic denervation among the treatment armamentarium in all patients with ventricular arrhythmias refractive to conventional medical therapy.

Reoperative aortic valve replacement in the octogenarians-minimally invasive technique in the era of transcatheter valve replacement.

OBJECTIVE: Reoperative aortic valve replacement (re-AVR) in octogenarians is considered high risk and therefore might be indicated for transcatheter AVR. The minimally invasive technique for re-AVR limits dissection and might benefit this patient population. We report the outcomes of re-AVR in high-risk octogenarians who might be considered candidates for transcatheter AVR to assess the safety of re-AVR and minimally invasive operative techniques. METHODS: We identified 105 patients, aged ≥80 years, who underwent open re-AVR at our institution from July 1997 to December 2011. Patients requiring concomitant coronary bypass surgery and/or other valve surgery were excluded. The outcomes of interest included operative mortality, postoperative complications, and midterm postoperative survival. RESULTS: Of the 105 patients, 51 underwent minimally re-AVR through upper hemisternotomy (Mre-AVR) and 54 standard full sternotomy (Fre-AVR). The mean patient age was 82.8 ± 3.8 years. No significant differences were found in the patient risk factors. Postoperatively, 6 patients (5.7%) underwent reoperation for bleeding, 4 (3.8%) experienced permanent stroke, 4 (3.8%) developed new renal failure, and 22 (21.0%) had new-onset atrial fibrillation. Overall, the operative mortality was 6.7%, and the 1- and 5-year survival was 87% and 53%, respectively. When Mre-AVR and Fre-AVR were compared, the operative mortality was 9.2% in the Fre-AVR group and 3.9% in the Mre-AVR group (P = .438). Kaplan-Meier analysis showed a survival benefit at both 1 year (79% ± 11.7% vs 92% ± 7.8%) and 5 years (38% ± 17.6% vs 65% ± 15.7%, P = .028) favoring Mre-AVR. Cox regression analysis identified heparin-induced thrombocytopenia, reoperation for bleeding, older age, full sternotomy, and an infectious complication as predictors of mortality. CONCLUSIONS: Octogenarians who undergo re-AVR are thought to be high-risk surgical candidates. The present single-center series revealed acceptable in-hospital outcomes and operative mortality. Mre-AVR was associated with better survival compared with Fre-AVR and might benefit this population.

Human macrophage regulation via interaction with cardiac adipose tissue-derived mesenchymal stromal cells.

BACKGROUND: Mesenchymal stromal cells (MSCs) improve tissue repair but their mechanism of action is not fully understood. We aimed to test the hypothesis that MSCs may act via macrophages, and that specifically, human cardiac adipose tissue-derived mesenchymal stromal cells (AT-MSCs) can polarize human macrophages into a reparative, anti-inflammatory (M2) phenotype. Methods and RESULTS: We isolated and grew AT-MSCs from human cardiac adipose tissue obtained during cardiac surgery. Macrophages were grown from CD14(+) monocytes from healthy donor blood and then cocultured with AT-MSCs, with and without transwell membrane, for 1 to 14 days. In response to AT-MSCs, macrophages acquired a star-shaped morphology, typical of alternatively activated phenotype (M2), and increased the expression of M2 markers CD206(+), CD163(+), and CD16(+) by 1.5- and 9-fold. Significantly, AT-MSCs modified macrophage cytokine secretion and increased the secretion of anti-inflammatory and angiogenic cytokines: interleukin (IL)-10 (9-fold) and vascular endothelial growth factors (3-fold). Moreover, AT-MSCs decreased macrophage secretion of inflammatory cytokines such as IL-1α (2-fold), tumor necrosis factor α (1.5-fold), IL-17 (3-fold), and interferon gamma (2-fold). Remarkably, the interaction between AT-MSCs and macrophages was bidirectional and macrophages enhanced AT-MSC secretion of typical M2 inducers IL-4 and IL-13. Notably, AT-MSCs decreased macrophage phagocytic capacity. Finally, IL-6 mediates the M2 polarization effect of AT-MSCs on macrophages, by increasing M2-associated cytokines, IL-10 and IL-13. CONCLUSIONS: Human cardiac AT-MSCs can polarize human macrophages into anti-inflammatory phenotype. Our findings suggest a new mechanism of action of AT-MSCs that could be relevant to the pathogenesis and treatment of myocardial infarction, atherosclerosis, and various cardiovascular diseases.

Higher levels of serum cytokines and myocardial tissue markers during on-pump versus off-pump coronary artery bypass surgery.

Increased Troponin I levels and pro-inflammatory cytokines have been reported in most patients undergoing cardiac surgery, ascribed to the type and extent of surgery, reperfusion injury, and the method of myocardial protection. We investigated their levels in patients undergoing on-pump (CCAB) or off-pump (OPCAB) coronary artery bypass surgery and whether these correlated with the extent of myocardial injury. One hundred twenty patients were prospectively randomized to undergo OPCAB (n = 60) or CCAB (n = 60). Hemodynamic and respiratory data, as well as serum CK-MB mass fraction, Troponin I, and interleukin (IL)-6, IL-8, and IL-10 levels, were collected perioperatively. Demographic, hemodynamic, and respiratory parameters were similar between the two groups. Troponin I was significantly lower in the OPCAB than in the CCAB group, either at the end of ischemia, end of surgery, 6-hour and 24-hour postoperatively (4 +/- 3, 5 +/- 3, 7 +/- 5, and 8 +/- 3 microg/L, vs. 19 +/- 18, 27 +/- 19, 28 +/- 13.5, and 33 +/- 8.5 microg/L, respectively, p < 0.05). Serum cytokine levels in the OPCAB patients were lower compared to the CCAB group at the end of surgery (32 +/- 35, 25 +/- 30, and 40 +/- 30 pg/ml for IL-6, IL-8, and IL-10 vs. 230 +/- 30, 140 +/- 70, and 125 +/- 50 pg/ml, respectively, p < 0.05). Plasma IL-6 levels correlated with the Troponin I levels at the end of surgery in both groups (r = 0.45, p = 0.01). Thus, OPCAB surgery is associated with reduced levels of Troponin I and activation of cytokines, compared to those in the CCAB group. High levels of these factors could correlate with myocardial damage during coronary artery bypass surgery. This finding warrants further laboratory and clinical confirmation in the future.