Minimally Invasive Mitral Valve Surgery With Concomitant Cox Maze Procedure Is as Effective as a Median Sternotomy With Decreased Morbidity.

OBJECTIVE: A right minithoracotomy (RMT) is a minimally invasive surgical approach that has been increasingly performed for the concomitant Cox maze IV procedure (CMP) and mitral valve surgery (MVS). Little is known regarding whether long-term rhythm and survival outcomes are affected by the RMT as compared with the traditional median sternotomy (MS) approach. METHODS: Between April 2004 and April 2021, 377 patients underwent the concomitant CMP and MVS, of whom 38% had RMT. Propensity score matching yielded 116 pairs. Freedom from atrial tachyarrhythmias (ATA) was assessed with prolonged monitoring annually for 8 years. Survival, rhythm, and perioperative outcomes were compared. RESULTS: The unmatched RMT cohort had a greater freedom from ATA recurrence at 1 year (99% vs 90%, P = 0.001) and 3 years (94% vs 86%, P = 0.045). The matched RMT cohort had longer cardiopulmonary bypass (median: 215 [199 to 253] vs 170 [136 to 198] min, P < 0.001) and aortic cross-clamp (110 [98 to 124] vs 86 [71 to 102] min, P < 0.001) times but shorter intensive care time (48 [24 to 95] vs 71 [26 to 144] h, P = 0.001) and length of stay (8 [6 to 11] vs 10 [7 to 14] h, P < 0.001). More pacemakers (18% vs 4%, P < 0.001) and postoperative transfusions (57% vs 41%, P = 0.014) occurred in the MS cohort. The 30-day mortality (P = 0.651) and 8-year survival (P = 0.072) was not significantly different between the cohorts. CONCLUSIONS: Early 1-year and 3-year freedom from ATA recurrence was better in the RMT cohort compared with the MS cohort. Despite longer operative times, the RMT cohort had shorter lengths of stay, fewer postoperative transfusions, and fewer pacemakers placed.

Performance of an Irrigated Bipolar Radiofrequency Ablation Clamp on Explanted Human Hearts.

BACKGROUND: Bipolar radiofrequency (RF) clamps are commonly used during surgical ablation for atrial fibrillation (AF). This study examined the efficacy of an irrigated bipolar RF clamp to create transmural lesions in an ex vivo human heart model. METHODS: Ten donor hearts, turned down for transplantation, were explanted and arrested with cold cardioplegia. The ablations of the Cox Maze IV procedure were performed using the Cardioblate LP (Medtronic, Inc) irrigated bipolar RF clamp. In the first 5 hearts, each lesion was created with a single application of RF, whereas in the remaining 5 hearts, each lesion was created with a double application of RF without unclamping. Each lesion was cross-sectioned and stained with 2,3,5-triphenyl-tetrazolium chloride to assess ablation depth and transmurality. RESULTS: A total of 100 lesions were analyzed. In the single-ablation group, 222 of 260 sections (85%) and 37 of 50 lesions (74%) were transmural. The efficacy improved significantly in the double-ablation group, in which 348 of 359 sections (97%, P < .001) and 46 of 50 lesions (92%, P = .017) were transmural. Overall, in nontransmural lesions, the epicardial fat thickness was significantly greater (1.69 ± 0.70 mm vs 0.45 ±0.10 mm, P < .001) than the transmural lesions. CONCLUSIONS: A single ablation on human atrial tissue with an irrigated bipolar RF clamp was insufficient to reliably create transmural lesions, but a double ablation significantly increased the lesion and section transmurality. Nontransmural lesions were associated with significantly thicker layers of epicardial fat, which likely decreased tissue energy delivery due to the higher resistance of fat to current flow.

3D Transesophageal Echocardiography for Guiding Transcatheter Aortic Valve Replacement Without Prior Cardiac Computed Tomography in Patients With Renal Dysfunction.

BACKGROUND: Pre-procedural chronic kidney disease (CKD) and in-hospital acute kidney injury (AKI) are associated with worse outcomes following transcatheter aortic valve replacement (TAVR). We tested the feasibility of reducing overall AKI by avoiding pre-procedural cardiac CT angiography (CCTA) by using direct 3D-TEE guidance in TAVR patients with known CKD. METHODS: An institutional TAVR database was examined from January 2016 to June 2020 to identify 396 patients in whom CCTA sizing was performed and 54 patients with creatinine (Cr) of >1.6 mg/dL in whom direct 3D-TEE, without prior CCTA, was used for TAVR guidance. Baseline demographics, procedural, echocardiographic, and clinical endpoints were compared as defined by the Valve Academic Research Consortium-2 criteria. RESULTS: Baseline demographics and risk factors were similar in both groups other than the creatinine level in CCTA vs. TEE groups (1.33 ± 1.1 vs 1.76 ± 0.7 mg/dL, p = 0.005). Procedural contrast volume was significantly lower in the TEE group compared to the CCTA group. No differences were noted in echocardiographic and clinical endpoints for both groups. Despite higher baseline Cr, patents in the TEE group experienced a similar pattern of changes in Cr compared to the CCTA group, with an overall renal improvement noted at the time of discharge for both groups. CONCLUSIONS: In patients with baseline CKD, careful avoidance of large contrast loads associated with CCTA and intra-procedural aortography by using TEE guidance may help reduce AKI following TAVR.

Erratum: A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery.

Figure Legends Corrected: Figure 1. Intraoperative transesophageal echocardiogram, midesophageal right ventricular infow-outflow view, initial operation September 2018. Figure 2. Intraoperative transesophageal echocardiogram, midesophageal right ventricular inflow-outflow view, second operation January 2019. Figure 3. Intraoperative transesophageal echocardiogram, midesophageal right ventricular inflow-outflow view, third operation March 2019. Reference: Jeffrey W. Cannon, J.W. Awori Hayanga, Thomas B. Drvar, Matthew Ellison, Christopher Cook, Muhammad Salman, Harold Roberts, Vinay Badhwar, Heather K. Hayanga. A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery. Am J Case Rep. 2021; 22: e927385, 10.12659/AJCR.927385.

Robotic assisted cryothermic biatrial Cox-Maze.

INTRODUCTION: Robotic cryothermic Cox-Maze (CM) IV is a minimally invasive procedure that reliably replicates the biatrial lesion set of the CM III by utilizing cryothermia as a single power source. METHODS: Herein we describe a step by step creation of the biatrial CM III lesion sets utilizing the minimally invasive robotic platform. RESULTS: Technical details are reviewed for this single incision, single stage, highly effective option for stand-alone or concomitant surgical ablation of atrial fibrillation (AF). CONCLUSION: Robotic cryothermic CM IV can be safely performed as a stand-alone or concomitant procedure, and offers a comprehensive surgical ablation solution for patients with AF.

A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery.

BACKGROUND Intravenous drug use is an epidemic in the United States. One of the complications of intravenous drug use can be infective endocarditis. The treatment for this disease is a combination of intravenous antibiotics, cardiac surgery consultation, and multidisciplinary psychiatric care. Despite surgical intervention, recurrence of disease is common. In the setting of recurrent infective endocarditis in the setting of intravenous drug use, the ethics of redo cardiac surgery has not been well-established. CASE REPORT A 34-year-old man with history of intravenous drug use presented on 3 separate occasions with infective endocarditis resulting in 3 tricuspid valve surgeries within fewer than 7 months. He said he had not injected drugs since before his first operation, he was considered to have a strong social support system, and he completed his postoperative antibiotic regimens each time. However, prior to his last operation, the patient had a urine drug screen positive for opiates without recorded prescribed opioids. Pathology reports from the 3 intraoperative specimens showed different pathogens each time. An extensive interprofessional discussion ensued. CONCLUSIONS Infective endocarditis in the setting of intravenous drug use and its treatments continue to be a point of ethical and medical discussion for all professionals involved with the care of these patients. This case could be used as an example of individualized decision-making, with rigorous ethical and medical discussion factoring into each decision for cardiac surgery. The ongoing treatment for patients with recurrent endocarditis in the setting of intravenous drug use requires more research and guidelines to help medical professionals better care for this patient population.

Six-Month Performance of a 3-Dimensional Annuloplasty Ring for Repair of Functional Tricuspid Regurgitation.

BACKGROUND: Functional tricuspid regurgitation (FTR) secondary to left-sided heart disease may lead to poor quality of life and reduced long-term survival. This study evaluated clinical and functional outcomes of patients undergoing tricuspid valve (TV) repair using a rigid three-dimensional ring (Contour 3D, Medtronic) concomitant with another procedure. METHODS: From September 2011 to July 2015, 112 patients (mean age 70.9 ± 9.0 years) were enrolled at 10 centers in Europe, Israel, and the United States. Inclusion criteria were FTR ≥ moderate and/or tricuspid annular diameter (TAD) ≥ 40 mm. Echocardiography was planned before surgery and at discharge with echocardiographic and clinical follow-ups performed 6 months postoperatively. RESULTS: Three fourths (74.4%) of patients had higher than moderate TR. Mean TAD was 41.0 ± 7.3 mm; 61.7% of patients were in the New York Heart Association (NYHA) class III/IV. The most common concomitant procedure was mitral valve repair (57 patients, 53.3%). The 30-day mortality rate was 0.9% (n = 1). The mean EuroSCORE II was 8.9 ± 8.4% (median: 5.9%; interquartile range: 3.5-11.5%). The observed to expected ratio (O/E) based on the median was 0.1. Six deaths occurred during follow-up (three cardiac related). Mean implanted ring size was 30.3 ± 2.7. At 6 months, 94.4% of patients showed ≤ mild TR, and 92.0% were in NYHA class I/II (p < 0.001 vs baseline for both). Mean pressure gradient across the TV was 2.0 ± 1.1 mm Hg; leaflet coaptation length was 7.5 ± 3.3 mm. CONCLUSION: The Contour 3D annuloplasty ring used for treatment of FTR substantially reduced TR for up to 6 postoperative months with low mean pressure gradients across the TV and significant improvement in NYHA class. REGISTRATION: www.ClinicalTrials.gov, NCT01532921.

Surgical Treatment for Stand-Alone Atrial Fibrillation in North America.

BACKGROUND: Surgical treatment of symptomatic atrial fibrillation has been performed for 3 decades. We reviewed trends and outcomes of surgical ablation (SA) for stand-alone atrial fibrillation using The Society of Thoracic Surgeons Adult Cardiac Surgical Database (STS-ACSD). METHODS: The STS-ACSD was reviewed from 2011 to 2017 (N = 7187) for trends. Contemporary data from 2014 to 2017 (n = 3893) were used to compare three subgroups: off pump (n = 3252), on pump (n = 491), and patients with incision conversion or conversion from off pump to on pump (n = 150). Propensity score matching was conducted to balance groups. RESULTS: Annual growth of stand-alone SA was 7%. Median age of patients was 64 years (interquartile range, 57 to 70), and 30% were female. Overall 30-day mortality was 0.8% and perioperative stroke incidence was 0.8%. Most SA procedures were off pump (84%), with 12% greater odds for off pump per year (odds ratio [OR] 1.12, P < .001). The off-pump group had fewer biatrial SA (21% vs 71%, P < .001) and left atrial appendage obliterations (53% vs 95%, P < .001) compared with the on-pump group. After matching, uneventful off-pump SA had similar mortality (0.4% vs 0.9%, P = .292) vs on-pump SA, but reduced incidence of renal failure (0.9% vs 2%, P = .033). After risk adjustment, the conversion group had worse perioperative outcomes vs the off-pump group, including greater incidence of stroke (OR 5.37, P < .001) and operative mortality (OR 9.98, P < .001). Mortality (OR 4.69, P = .011) was also greater for conversion vs on pump. CONCLUSIONS: Steady growth of stand-alone SA operations was noted. Procedures performed either on pump or off pump were relatively safe. However, intraoperative conversion was associated with significantly higher morbidity and mortality. Patient selection, improvement of surgical techniques, and long-term follow-up should be emphasized to improve decision making and outcome.