Impact of Persistent Versus Paroxysmal Preoperative Atrial Fibrillation on In-Hospital, One-Year and Late Clinical Outcomes Following Transcatheter Aortic Valve Implantation.

Prior reports on the impact of pre-existing atrial fibrillation (AF) on clinical outcomes following transcatheter aortic valve implantation (TAVI) have presented limited data on the relative impact of paroxysmal versus persistent AF sub-types. We compared in-hospital, 1-year and late clinical outcomes in 1,098 TAVI patients with preoperative AF (556 paroxysmal, 542 persistent) versus 1,787 No-AF patients. Propensity matched AF (n=643) and No-AF (n=686) cohorts did not differ with respect to baseline clinical characteristics, operative technique or in-hospital TAVI complications. At 1-year, AF patients had higher all-cause mortality (9.0 vs 6.1%, p=0.046) and readmission rates (13.1 vs 8.8%, p=0.014), with lower KCCQ12 scores (77.8±21.8 vs 84.3±17.1, p<0.001). Echocardiographic follow-up (mean time 455 ± 285 days) demonstrated no significant inter-group differences in hemodynamic findings other than a progressive increase in left atrial volume index (LAVI) in patient subgroups (No-AF:37.4±14.7 ml/m2 vs paroxysmal AF: 46.4±21.4 ml/m2 vs persistent AF: 60.5±26.3 ml/m2; p<0.001). On late follow-up (mean time 49.0 (45.1-52.9) months), patients with persistent AF had worse all-cause mortality compared to No-AF patients (HR: 1.55; 95% CI: 1.17-2.06, p=0.003), with no significant survival differences between the paroxysmal AF and No-AF subgroups. In conclusion, pre-existing AF compared to No-AF TAVI patients had similar in-hospital outcomes, but worse 1-year mortality, hospital readmission and quality of life outcomes. Compared to No-AF patients, patients with persistent, but not paroxysmal preexisting AF, have higher late all-cause mortality at a mean follow-up of 49 months. Patients with persistent AF have higher levels of LAVI compared to paroxysmal and No-AF patients on intermediate echocardiographic follow-up.

Half-dose direct oral anticoagulation versus warfarin for atrial fibrillation following cardiac surgery.

BACKGROUND: Optimal anticoagulation strategies have not been defined for patients with atrial fibrillation following cardiac surgery. METHODS: From a total cohort of 228 patients with pre-existing or new onset atrial fibrillation following coronary artery bypass grafting and/or valve surgery, we compared in-hospital and 30-day outcomes in 119 patients treated with low-dose aspirin and a half-dose direct oral anticoagulant (DOAC) versus 109 treated with low-dose aspirin and warfarin. RESULTS: DOAC patients were older (73.1±7.0 vs. 68.7±11.4 years, P<0.001) and had a lower incidence of preoperative atrial fibrillation (37 [31.1%] vs. 69 [63.3%], P<0.001). Otherwise, the two cohorts were well matched for baseline demographics, cardiovascular risk factors, comorbidities, prior cardiac history and STS Risk Score. In comparison to Warfarin patients, DOAC patients had a shorter length of post-surgical stay (6 [5-8] vs. 7 [5-10] days, P=0.037). The two cohorts, however, had a similar incidence of stroke, transient ischemic attack, reoperation for bleeding and postoperative blood bank product usage. Follow-up 30-day outcomes did not differ between the two groups with respect to mortality (0 [0.0%] vs. 0 [0.0%], P=1.000) and hospital readmission (16 [13.4%] vs. 14 [12.8%], P=0.893), although two DOAC patients required drainage of sanguineous pericardial effusions. CONCLUSIONS: In comparison to warfarin, half-dose DOAC anticoagulation in patients with atrial fibrillation following cardiac surgery is associated with a shorter postoperative length of stay, without a significant increase in stroke/transient ischemic attack, reoperation for bleeding or postoperative blood product transfusion. Follow-up echocardiography in anticoagulated patients is recommended to rule out significant sanguineous pericardial effusions in the early postoperative period following hospital discharge.

Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching.

OBJECTIVE: To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG). DESIGN: A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS. SETTING: At a tertiary care teaching hospital. PARTICIPANTS: A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (ß2 coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods. CONCLUSIONS: Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.

Impact of Ticagrelor Versus Clopidogrel on Bleeding Outcomes of Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Increased bleeding risks have been documented in patients exposed to P2Y12 inhibitors within 5 days of coronary artery bypass surgery (CABG). This study aimed to determine the relative CABG bleeding risks of clopidogrel versus ticagrelor exposure and the proper time course of ticagrelor discontinuation prior to surgery. METHODS: Clinical outcomes were assessed in 2075 isolated CABG patients, including 375 who had received P2Y12 inhibitors within 5 days of surgery (155 clopidogrel, 213 ticagrelor, 7 prasugrel). BARC-4 CABG bleeding complications and perioperative blood product usage were assessed in propensity-matched P2Y12-inhibited and non-P2Y12-inhibited cohorts. RESULTS: P2Y12-inhibited patients (n = 375) in comparison to matched non-P2Y12-inhibited patients (n = 1138) had higher rates of re-operation for bleeding (3.8 % vs 1.3 %, p = 0.003), postoperative red blood cell transfusion ≥5 units (5.7 % vs 2.7 %, p = 0.007), and intraoperative and postoperative blood product utilization (42.3 % vs 27.1 %, p < 0.001; 41.8 % vs 32.2 %, p < 0.001, respectively). Univariate predictors of BARC-4 bleeding included clopidogrel (OR: 2.145, 95 % CI: 1.131-4.067, p = 0.019) and ticagrelor discontinued within 3 days of surgery (OR: 2.153, 95 % CI: 1.003-4.169, p = 0.049). Multivariate logistic regression demonstrated that only clopidogrel exposure was an independent BARC-4 bleeding predictor (OR: 1.850, 95 % CI: 1.007-3.398, p = 0.048). Unadjusted ticagrelor patients with drug discontinuation 4-5 days prior to CABG only demonstrated higher rates of perioperative platelet transfusion, without additional signs of excessive bleeding. CONCLUSIONS: Clopidogrel exposure within 5 days of CABG is an independent predictor of BARC-4 bleeding, whereas major ticagrelor bleeding effects are confined to drug exposure within 3 days of surgery.

Propensity-matched comparison of right mini-thoracotomy versus median sternotomy for isolated mitral valve repair.

BACKGROUND: A right mini-thoracotomy (RT) versus median sternotomy (MS) approach for isolated mitral valve (MV) repair has been associated with less postoperative morbidity, shorter hospital stay, and faster functional recovery, but with consistently longer cross-clamp time and higher operative costs. METHODS: We assessed the impact of a modified operative technique on outcomes in 158 RT versus 129 MS patients treated with myxomatous MV repair from 2016 through 2021. Propensity matching based upon the Society of Thoracic Surgeons Risk Score was used to compare 108 patients in each cohort. RESULTS: Propensity-matched RT patients had reductions in total ventilation time (P=0.025), postoperative atrial fibrillation (P=0.019), and hospital length of stay (P<0.001). RT and MS patients had similar cross-clamp times (66.4±13.7 vs 64.8±16.0 minutes, P=0.414), with less overall leaflet resection (32.4% vs 57.4%, P<0.001) and fewer Gore-Tex NeoChords implanted per patient (1.7±0.7 vs 2.1±1.0, P=0.028) in the RT group. The two cohorts did not differ with respect to 30-day major surgical complications. No patient died and there was no difference between the two groups with respect to freedom from re-operation (98.2% vs 98.2%, P=0.800) at a mean follow-up of 21.4±18.5 months. Direct total hospital costs were lower for the RT group (P=0.018), with reductions in postoperative charges offsetting increased operating room costs. CONCLUSIONS: In this single-center study, the RT compared to the MS approach for myxomatous MV repair resulted in less postoperative morbidity and shorter hospital length of stay, with similar cross-clamp time, reduced total hospital costs, and comparable intermediate outcomes.

Rupture of GORE-TEX neochordae 10 years after mitral valve repair.

The current non-resectional paradigm in mitral valve (MV) repair emphasizes the use of polytetrafluoroethylene (PTFE) for artificial chordal replacement. While excellent long-term durability of repair using PTFE neochordae has been established, there have been rare reports of neochordal rupture at various times after surgery. We report a case of artificial chordal rupture 10 years after anterior mitral leaflet repair, necessitating reoperation. This complication may have been precipitated by maldistributed intracardiac tensile forces as a consequence of a malpositioned annuloplasty band.

Intraoperative Bioprosthetic Valve Dysfunction Causing Severe Mitral Regurgitation.

Structural degeneration of bioprosthetic valves usually occurs gradually over time. Failure of a bioprosthetic valve immediately after implantation is extremely rare. Possible causes include obstruction of valve leaflets from preserved subvalvular tissue during chordal-sparing mitral valve replacement (MVR) or strut entrapment by suture loops. We report 2 cases of acute bioprosthetic mitral valve (MV) dysfunction involving newly implanted Perimount Theon (Edwards Lifesciences, Irvine, CA) bioprostheses, causing severe transvalvular mitral regurgitation (MR). Rapid diagnosis was achieved with the use of intraoperative transesophageal echocardiography (TEE). Operative assessment and examination of the explanted valves could not determine a definite cause of failure in either case.

Antegrade Cardioplegia Decannulation Using the COR-KNOT System in Minimally Invasive Mitral Valve Surgery.

A right mini-thoracotomy approach may be used for mitral valve repair without compromising clinical outcomes. Compared with conventional sternotomy, there is an increased distance to the cardiac structures from the mini-thoracotomy incision, which makes certain technical acts more demanding. One particular challenge is hemostasis at the antegrade cardioplegia cannula site. We propose a novel technique to remove an antegrade cardioplegia cannula using the COR-KNOT system. This technique negates the need for tying with a knot pusher and reduces the risk of aortic injury and troublesome bleeding.

Equipoise between radial artery and right internal thoracic artery as the second arterial conduit in left internal thoracic artery-based coronary artery bypass graft surgery: a multi-institutional study†.

OBJECTIVES: Multiple arterial coronary artery grafting (MABG) improves long-term survival compared with single arterial CABG (SABG), yet the best second arterial conduit to be used with the left internal thoracic artery (LITA) remains undefined. Outcomes in patients grafted with radial artery (RA-MABG) versus right internal thoracic artery (RITA-MABG) as the second arterial graft were compared with SABG. METHODS: Multi-institutional, retrospective analysis of non-emergent isolated LITA to left anterior descending coronary artery CABG patients was performed using institutional Society of Thoracic Surgeon National Adult Cardiac Surgery Databases. 4484 (54.5%) SABG [LITA ± saphenous vein grafts (SVG)], 3095 (37.6%) RA-MABG (RA ± SVG) and 641 (7.9%) RITA-MABG (RITA ± SVG) patients were included. The RITA was used as a free (68%) or in situ (32%) graft. RA grafts were principally anastomosed to the ascending aorta. Long-term survival was ascertained from US Social Security Death Index and institutional follow-up. Triplet propensity matching and covariate-adjusted multivariate logistic regression were used to adjust for baseline differences between study cohorts. RESULTS: Compared with the SABG cohort, the RITA-MABG cohort was younger (58.6 ± 10.2vs65.9 ± 10.4, P < 0.001), had a higher prevalence of males (87% vs 65%, P < 0.001) and was generally healthier (MI: 36.7% vs 56.7%, P < 0.001, smoking: 56.8% vs 61.1%, IDDM: 3.0% vs 14.4%, CVA: 2.6% vs 10.0%). The RA-MABG cohort was generally characterized by a risk profile intermediate to that of SABG and RlTA-MABG. Unadjusted 5-, 10- and 15-year survival rates were best in RITA-MABG (95.2%, 89% and 82%), intermediate in RA-MABG (89%, 74%, 57%) and worst in SABG (82%, 61% and 44%) cohorts (all P < 0.001). Propensity matching yielded 551 RA-MABG, RITA-MABG and SABG triplets, which showed similar 30-day mortality. Late survival (16 years) was equivalent in the RA-MABG and RITA-MABG cohorts [68.2% vs 66.7%, P = 0.127, hazard ratio (HR) = 1.28 (0.96-1.71)] and both significantly better than SABG (61.1%). The corresponding SABG versus RITA-MABG and SABG versus RA-MABG HRs (95% confidence interval) were 1.52 (1.18-1.96) and 1.31 (1.01-1.69) with P < 0.002 and P = 0.038, respectively. CONCLUSIONS: RA-MABG or RITA-MABG equally improve long-term survival compared with SABG and thus should be embraced by the Heart Team as the therapy of choice in LITA-based coronary artery bypass surgery.

The imbrication technique: an alternative to the sliding leaflet technique.

Systolic anterior motion (SAM) represents a common and troublesome complication of mitral valve repair. The prevention of SAM has traditionally been based on the sliding leaflet technique, which involves resection of posterior leaflet tissue. However, this approach has not been universally adopted owing to its technical difficulty and inconsistent efficacy. We present an imbrication technique that avoids additional leaflet resection and achieves a reliable prevention of SAM. The approach has been successfully implemented in the treatment of 124 consecutive patients at high risk for SAM.

The "free" right internal thoracic artery: a versatile and durable conduit.

BACKGROUND: Despite its potential advantages, the right internal thoracic artery (RITA) is used as a conduit in only 4% of coronary revascularizations. To broaden its application, we frequently use the RITA as a free graft. In this study, we review our experience with the RITA as an in situ and free graft. METHODS: We reviewed the perioperative outcomes and angiographic patency rates of 479 consecutive patients who underwent RITA grafting between January 1987 and December 2011. RESULTS: The RITA was harvested free (FRITA) in 380 patients (79%) and in situ in 99 (21%). The predominant target for the in situ RITA was the right coronary system (79%). The predominant targets for the FRITA were divided between the right (54%) and left coronary systems (46%). There was no perioperative mortality. Mean follow-up was 10 years. Perioperative complications included myocardial infarction (0.4%), sternal nonunions (0.4%), and reoperation for hemorrhage (0.6%). Coronary angiograms were performed in symptomatic patients (17%) after a median of seven years. FRITA patency rates at five, 10, and 15 years were 100%, 95%, and 95%, respectively, comparable to the left internal thoracic artery patency rates and superior to those of saphenous vein graft. Survival rates of FRITA patients at 10, 15, and 20 years were 92%, 89%, and 76%, respectively. CONCLUSION: The FRITA graft reaches all distal coronary vessels and is associated with excellent patency and survival rates. Its application in coronary revascularization vastly expands the benefits of internal thoracic artery grafting.

Liver laceration from a diaphragmatic suture in minithoracotomy mitral valve repair.

Mitral valve operations are increasingly performed through minimally invasive approaches such as the right anterior minithoracotomy. To facilitate exposure with this technique, a diaphragmatic suture may be implemented. We describe a liver laceration caused by the diaphragmatic suture in minithoracotomy mitral repair and its successful nonoperative management with arterial embolization.

Outcomes for mitral valve surgery among Medicare fee-for-service beneficiaries, 1999 to 2008.

BACKGROUND: Mitral valve surgery in older adults carries with it substantial morbidity and mortality risks, yet there are a paucity of national surveillance data. Therefore, we sought to determine trends in hospitalization rate, readmission, and mortality among Medicare fee-for-service (FFS) patients undergoing mitral valve surgery. METHODS AND RESULTS: Inpatient Medicare standard analytic files were used to identify 100% of FFS patients aged ≥ 65 years who underwent mitral valve surgery between 1999 and 2008. We constructed a denominator file from Medicare administrative data to report hospitalization rates for mitral valve surgery (total and isolated) per 100 000 beneficiary-years. For isolated mitral valve surgery, 30-day readmission, 30-day mortality, and 1-year mortality outcomes were ascertained through corresponding inpatient and vital status files, and risk-standardized rates were calculated adjusting for age, sex, race, and comorbidities. During 1999 to 2008, the overall rate of mitral valve surgery per 100K beneficiary-years declined (56/100K to 51/100K), and the proportion of patients undergoing mitral valve repair (versus replacement) increased (24.7% to 46.9%, P<0.001). For isolated mitral valve surgery, there were significant declines in risk-adjusted 30-day mortality (8.1% to 4.2%, P<0.001 for trend) and 1-year mortality (15.3% to 9.2%, P=0.003 for trend) and a slight decline in risk-adjusted 30-day readmission (23.0% to 21.0%, P=0.035 for trend) over the study period. Mortality rates decreased in all age, sex, and race subgroups, and among patients undergoing mitral valve repair or replacement, but remained higher among patients aged ≥ 85 years, women, and nonwhites. CONCLUSIONS: Between 1999 and 2008, outcomes after isolated mitral valve surgery significantly improved among Medicare FFS patients. Disparities among demographic subgroups indicate potential areas for quality improvement.

Pseudoprolapse of the anterior leaflet in chronic ischemic mitral regurgitation: identification and repair.

OBJECTIVE: Recurrence rates as high as 30% have been observed 6 months after treatment of chronic ischemic mitral regurgitation (CIMR) with isolated annuloplasty. We postulated that the high early recurrence rates resulted from the presence of untreated pseudoprolapse of the anterior leaflet. METHODS: We conducted a retrospective study of all mitral valve repairs for CIMR performed by a single surgeon (S.W.H.) from 1995 to 2011. After annuloplasty, Gore-Tex neochordae were added if the high-pressure saline test indicated the presence of pseudoprolapse of the anterior leaflet. RESULTS: A total of 47 patients underwent mitral valve repair for CIMR. Of the 47 patients, 24 (51%) were found to have pseudoprolapse requiring the addition of neochordae. For all patients, the average age was 65.1 years, and 65.2% were men. Fourteen (30%) had had a preoperative intra-aortic balloon pump placed by cardiologists. Fourteen (30%) had severe pulmonary hypertension. Concomitant coronary artery bypass grafting was performed in 40 patients, with an average of 2.2 grafts; 7 had previously undergone coronary artery bypass grafting. Mitral Carpentier-Edwards physio annuloplasty rings were used in all patients with a mean size of 29 mm. One patient died postoperatively. Follow-up data were available for all 47 patients at an average of 4.9 years. The 5-year survival rate was 82.5%. The mean pre- and postoperative New York Heart Association class, ejection fraction, and mitral regurgitation grade were 3 and 1.52 (P < .0001), 34% and 41% (P = .0006), and 3.51 and 1.08 (P < .0001), respectively. Two patients developed greater than moderate mitral regurgitation. CONCLUSIONS: Effective repair of CIMR should include surgical techniques to correct pseudoprolapse of the anterior leaflet, when present. The selective addition of Gore-Tex neochordae to an undersized annuloplasty nearly eliminates recurrent regurgitation after mitral valve repair for CIMR.

Solving the puzzle of chronic ischemic mitral regurgitation.

Chronic ischemic mitral regurgitation is a prevalent problem among patients following a myocardial infarction. Until recently, the pathophysiology was poorly understood, resulting in surgical strategies with suboptimal results and limited durability. The surgical approach has evolved from revascularization alone to an additional mitral valve procedure, replacement, or repair. When the valve was repaired, isolated annuloplasty was performed. The dilemma that surgeons had when repairing a mitral valve was which type of ring to use and what size. In all series with annuloplasty alone, the results were poor with very high recurrence rates. The primary feature of ischemic mitral regurgitation is a prolapse of the anterior leaflet at A3 +/- A2. This prolapse can be caused by fibrotic elongation of the papillary muscle supporting A3 +/- A2 or tethering of P3 by a ballooning posterior left ventricular wall. Using a technique that corrects this prolapse with Gore-Tex neochords, we have achieved excellent results with effective and durable correction of the ischemic mitral regurgitation.

Atrial fibrillation and mitral valve repair.

Atrial fibrillation (AF) is present in 30-40% of patients presenting for mitral valve surgery. In patients undergoing mitral valve repair, the presence of AF may be associated with increased mortality and morbidity and this is also the case in patients in whom AF persists postoperatively. Advances in understanding the pathogenesis of AF led to techniques that include both mitral valve repair and ablation of AF. The concomitant surgical treatment of AF during mitral surgery has become a commonly performed procedure, which was shown to be safe and which may improve the outcome for patients. AF after mitral valve replacement is an accepted indication for anticoagulation, but the data supporting anticoagulation in patients after mitral valverepair who convert to sinus rhythm are sparse. This article reviews the available data regarding outcomes of mitral repair and how they are influenced by AF and its therapy.