Efficacy of nasal continuous positive airway pressure as a preferred airway management during intravenous sedation of patients undergoing transcatheter aortic valve replacement.

Background: As the incidence of aortic stenosis is increasing in correlation with the aging population, symptomatic patients commonly require valve replacement procedures. If left untreated, symptomatic aortic stenosis can lead to death in 2 to 3 years. Often, transcatheter aortic valve replacement (TAVR) procedures are performed with the assistance of oxygenation via nasal cannula. However, oxygenation achieved through a nasal continuous positive airway pressure (nCPAP) device could be a more optimized strategy for patients without any sacrifice in efficacy compared to nasal cannula. Methods: A retrospective chart review was conducted on 28 patients at Baylor University Medical Center who presented to the operating room for a TAVR between January and October 2021. Fourteen patients received oxygenation via nasal cannula (control group) and 14 received oxygenation with nCPAP. Information gathered included method of oxygenation, length of stay, episodes of hypoxia (defined as sustained oxygen saturation <92% for at least 1 minute), paravalvular leak, pacemaker placement, and mean atrial valve (AV) gradient before and after the procedure. Results: In the nCPAP group, the average length of stay was 2.79 days vs 2.71 days in the nasal cannula group. In the nCPAP group, no patient required a permanent pacemaker, while the nasal cannula group had a 40% rate of permanent pacemaker placement. The average preprocedure AV gradient was 51.14 in the nCPAP group and 42.57 in the nasal cannula group. The average postprocedure AV gradient was 8.5 in the nCPAP group and 5.36 in the nasal cannula group. Both groups had an intensive care unit admission rate of 0%. The rate of paravalvular leak was 35.7% in the nCPAP group and 28.6% in the nasal cannula group. The nCPAP group had an average of 0 episodes of hypoxia and the nasal cannula group had an average of 0.93 episodes of hypoxia. Conclusion: The findings demonstrate the viability of nCPAP as an effective method of oxygenation during intravenous sedation of TAVR patients when compared to oxygenation achieved via nasal cannula during TAVRs.

Comparison of Echocardiographic and Catheter Mean Gradient to Assess Stenosis After Transcatheter Aortic Valve Implantation.

Discordance exists between Doppler-derived and left heart catheterization (LHC)-derived mean gradient (MG) in transcatheter aortic valve implantation (TAVI). We compared echocardiographic parameters of prosthetic valve stenosis and LHC-derived MG in new TAVIs. In a retrospective, single-center study, intraoperative transesophageal echocardiogram (TEE)-derived MG, LHC-derived MG, and acceleration time (AT) were obtained before and after TAVI in 362 patients. Discharge MG, AT, and Doppler velocity index (DVI) using transthoracic echocardiogram (TTE) were also obtained. MG ≥10 mm Hg was defined as abnormal. During native valve assessment with pre-TAVI TEE and pre-TAVI LHC, Pearson correlation coefficient revealed a nearly perfect linear relation between both methods' MGs (r = 0.97, p <0.0001). Intraoperatively, after TAVI, Spearman correlation coefficient revealed a weak-to-moderate relation between post-TAVI TEE and LHC MGs (r = 0.33, p <0.0001). Significant differences were observed in categorizations between post-TAVI TEE MG and post-TAVI AT (McNemar test p = 0.0003) and between post-TAVI TEE MG and post-TAVI LHC MG (signed-rank test p <0.0001), with TEE MG more likely to misclassify a patient as abnormal. At discharge, 30% of patients had abnormal TTE MG, whereas 0% and 0.8% of patients had abnormal DVI and AT, respectively. Discharge TTE MG was not associated with death or hospitalization for heart failure at a median follow-up of 862 days. Post-TAVI Doppler-derived MG by intraoperative TEE was higher than LHC, despite being virtually identical before implantation. At discharge, patients were more likely to be classified as abnormal using MG than DVI and AT. Elevated MG at discharge was not associated with death or hospitalization for heart failure.

Combined Tricuspid Valve Repair and Orthotopic Liver Transplantation in a Patient With Severe Tricuspid Regurgitation and Pulmonary Hypertension.

Severe pulmonary hypertension and severe tricuspid regurgitation are often considered strict contraindications for orthotopic liver transplantation. A combined approach of tricuspid repair and subsequent liver transplantation could provide a novel approach for patients with severe pulmonary hypertension and tricuspid regurgitation to undergo orthotopic liver transplantation. A 62-year-old male with a history of end-stage renal disease on hemodialysis, cirrhosis, and third-degree atrioventricular heart block status post single lead pacemaker insertion presented for an orthotopic liver transplant. However, after placement of a Swan-Ganz catheter by the anesthesia team, the patient's central venous pressure was found to be high, and his mean pulmonary artery pressure was 40 mmHg. His case was canceled due to concern for poor postoperative outcomes after a subsequent transesophageal echocardiogram revealed a severely dilated right heart and 4+ tricuspid regurgitation with flow reversal into the hepatic veins. After discussion among the hospital's transplant committee, the patient was planned to have a tricuspid valve repair, liver transplant, and kidney transplant surgery several months later. The patient successfully underwent tricuspid valve repair and orthotopic liver transplant and then kidney transplant the following day.

Comparison of outcomes after transcatheter aortic valve implantation following home versus non-home discharge.

As more patients undergo transcatheter aortic valve implantation (TAVI), knowledge of 1-year mortality and associated factors becomes increasingly important. After other cardiac procedures, discharge location has been shown to be associated with 1-year mortality. We examined outcomes of TAVI patients discharged home vs an extended care facility (ECF). All TAVI patients from January 1, 2012, to December 31, 2017, were evaluated. Cox proportional hazard regression models with cubic splines were used to estimate the adjusted effect of discharge to ECF on 1-year mortality. A total of 957 (85.6%) patients discharged home were compared to 160 (14.3%) discharged to ECF. On univariate analysis, patients discharged home were younger and had a lower Society of Thoracic Surgeons Predicted Risk of Mortality, higher albumin, and fewer vascular complications and strokes. Patients discharged to ECF had a higher 30-day mortality (3.8% vs. 0.5%, P = 0.001) and 1-year mortality (25.7% vs. 8.3%, P < 0.001). Cox proportional hazard regression models showed increased risk of 1-year mortality for patients discharged to ECF. In conclusion, patients discharged to ECF had a higher 30-day and 1-year mortality. The strongest predictor of 1-year mortality was discharge to ECF. Society of Thoracic Surgeons Predicted Risk of Mortality score was not a predictor of 1-year mortality.

Hybrid intervention approach to coronary artery and valvular heart disease.

Coronary angiography is used to assess the burden of coronary artery disease prior to surgical valve repair/replacement and often leads to concomitant bypass and valve surgery. We sought to evaluate outcomes of an alternative, hybrid approach involving percutaneous coronary intervention (PCI) and valve surgery, assessing the rate of stent thrombosis as a primary outcome. We reviewed charts of consecutive patients who underwent planned PCI prior to surgical valve repair/replacement by a single surgeon from January 2008 to December 2016. We calculated rates of surgical complication, duration of dual antiplatelet therapy (DAPT) prior to surgery, and rates of stent thrombosis and in-stent restenosis. Twenty-four patients were included in this study. Surgery was performed a median of 52.5 days following PCI. DAPT was withheld an average of 8 days before and resumed an average of 4 days after surgery. Ninety-two percent of surgeries were minimally invasive. There were no bleeding complications, stent thromboses, or restenosis events. All patients survived the 1-year follow-up. For patients with mixed coronary and valvular heart disease, a heart team approach involving preoperative PCI followed by staged minimally invasive valvular surgery appears to be safe and warrants further exploration.

High-quality cardiac surgery through teamwork.

The high-quality cardiothoracic surgery program is primed for mindful effective surgery. The challenge lies in attaining mindful skills and efficiency. Herein is one journey toward high departmental quality over two decades.

Clinical Relevance of Baseline TCP in Transcatheter Aortic Valve Replacement.

AIMS: To investigate the influence of baseline thrombocytopenia (TCP) on short-term and long-term outcomes after transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: A total of 732 consecutive patients with severe, symptomatic aortic stenosis undergoing TAVR from January 2012 to December 2015 were included. Primary outcomes of interest were the relationship of baseline TCP with 30-day and 1-year all-cause mortality. Secondary outcomes of interest were procedural complications and in-hospital mortality in the same subgroups. The prevalence of TCP (defined as platelet count <150 × 109/L) at baseline was 21.9%, of whom 4.0% had moderate/severe TCP (defined as platelet count <100 × 109/L). Compared to no or mild TCP, moderate/severe TCP at baseline was associated with a significantly higher 30-day mortality (23.3% vs 2.3% and 3.1%, respectively; P<.001) and 1-year mortality (40.0% vs 8.3% and 13.4%, respectively; P<.001). In Cox regression analysis, moderate/severe baseline TCP was an independent predictor of 30-day and 1-year mortality (hazard ratio [HR], 13.18; 95% confidence interval [CI], 4.49-38.64; P<.001 and HR, 5.90; 95% CI, 2.68-13.02; P<.001, respectively). CONCLUSIONS: In conclusion, baseline TCP is a strong predictor of mortality in TAVR patients, possibly identifying a specific subgroup of frail patients; therefore, it should be taken into account when addressing TAVR risk.

One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease.

BACKGROUND: End-stage renal disease (ESRD) poses unique challenges in the treatment of patients with severe aortic stenosis. Although surgical valve replacement in ESRD patients has been associated with increased mortality, the outcomes from transcatheter aortic valve replacement (TAVR) are not clearly defined. METHODS: The CoreValve US Expanded Use Study is a prospective, nonrandomized study of TAVR in extreme-risk patients with comorbidities excluding them from the Pivotal Trial. We report on patients with ESRD. The primary endpoint was a composite of all-cause mortality or major stroke at 1 year. RESULTS: Ninety-six patients with ESRD underwent TAVR with the CoreValve (Medtronic, Minneapolis, MN) and have reached 1-year follow-up. Mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 16.2% ± 8.4%. The rate of all-cause mortality or major stroke at 1 year was 30.3%. The all-cause mortality rate was 5.3% at 30 days and 30.3% at 1 year. The rate at 1 year of any stroke or transient ischemic attack was 2.1%; major vascular injury was 5.2%; and new permanent pacemaker was 26.8%. Valve performance improved postprocedure and remained improved at 1 year (effective orifice area 1.71 cm2, mean gradient 9.33 mm Hg) CONCLUSIONS: Early mortality in patients with ESRD is comparable to previously published data on extreme-risk patients without ESRD, but our data suggest a higher mortality rate at 1 year for ESRD patients, likely due to comorbid conditions. Stroke and major vascular injury are infrequent, and improved valve hemodynamics are maintained at 1 year.

Dexmedetomidine infusion for analgesia up to 48 hours after lung surgery performed by lateral thoracotomy.

Patients undergoing a lateral thoracotomy for pulmonary resection have moderate to severe pain postoperatively that is often treated with opioids. Opioid side effects such as respiratory depression can be devastating in patients with already compromised respiratory function. This prospective double-blinded clinical trial examined the analgesic effects and safety of a dexmedetomidine infusion for postthoracotomy patients when administered on a telemetry nursing floor, 24 to 48 hours after surgery, to determine if the drug's known early opioid-sparing properties were maintained. Thirty-eight thoracotomy patients were administered dexmedetomidine intraoperatively and overnight postoperatively and then randomized to receive placebo or dexmedetomidine titrated from 0.1 to 0.5 µg·kg·h(-1) the day following surgery for up to 24 hours on a telemetry floor. Opioids via a patient-controlled analgesia pump were available for both groups, and vital signs including transcutaneous carbon dioxide, pulse oximetry, respiratory rate, and pain and sedation scores were monitored. The dexmedetomidine group used 41% less opioids but achieved pain scores equal to those of the placebo group. The mean heart rate and systolic blood pressure were lower in the dexmedetomidine group but sedation scores were better. The mean respiratory rate and oxygen saturation were similar in the two groups. Mild hypercarbia occurred in both groups, but periods of significant respiratory depression were noted only in the placebo group. Significant hypotension was noted in one patient in the dexmedetomidine group in conjunction with concomitant administration of a beta-blocker agent. The placebo group reported a higher number of opioid-related adverse events. In conclusion, the known opioid-sparing properties of dexmedetomidine in the immediate postoperative period are maintained over 48 hours.

Gross and histological features of excised portions of posterior mitral leaflet in patients having operative repair of mitral valve prolapse and comments on the concept of missing (= ruptured) chordae tendineae.

OBJECTIVES: The aim of the study is to describe gross and histological features of operatively excised portions of mitral valves in patients with mitral valve prolapse (MVP). BACKGROUND: Although numerous articles on MVP (myxomatous or myxoid degeneration, billowing or floppy mitral valve) have appeared, 2 virtually constant histological features have been underemphasized or overlooked: 1) the presence of superimposed fibrous tissue on both surfaces of the leaflets and surrounding many chordae tendineae; and 2) the absence of many chordae tendineae on the ventricular surfaces of the leaflets as the result of their being hidden (i.e., covered up) by the superimposed fibrous tissue. METHODS: We examined operatively excised portions of prolapsed posterior mitral leaflets in 37 patients having operative repair. RESULTS: Histological study of elastic-tissue stained sections disclosed that the leaflet thickening was primarily due to the superimposed fibrous tissue. All leaflets had variable increases in the spongiosa element within the leaflet itself with some disruption and/or loss of the fibrosa element and occasionally complete separation of it from the spongiosa element. Both the leaflet and chordae were separated from the superimposed fibrous tissue by their black-staining elastic membranes. CONCLUSIONS: These findings demonstrate that the posterior leaflet thickening in MVP is mainly due to the superimposed fibrous tissue rather than to an increased volume of the spongiosa element of the leaflet itself. The superimposed fibrous tissue on both leaflet and chordae is likely the result of subsequent abnormal contact of the leaflets and chordae with one another. Chordal rupture (i.e., missing chordae) occurred in all 37 patients, but finding individual ruptured chords was rare.

Risk of not being discharged home after isolated coronary artery bypass graft operations.

BACKGROUND: The age and risk profile of patients undergoing isolated coronary artery bypass grafting (CABG) is increasing, which will likely increase the proportion of CABG patients discharged to nursing homes, rehabilitation, or long-term care. Because discharge disposition can be important to a patient's treatment goals, developing and using predictive tools will improve informed treatment decision making. We examined the utility of The Society of Thoracic Surgeons (STS) risk of mortality score in predicting discharge disposition after CABG. METHODS: From January 1, 2004 to October 31, 2011, 5,119 patients underwent isolated CABG at The Heart Hospital Baylor Plano or Baylor University Medical Center (Texas) and were discharged alive. The association between STS risk of mortality and discharge to nursing home, rehabilitation, or long-term care was assessed using multivariable logistic regression, adjusted for age, body surface area, marital status, site, and year of operation. RESULTS: At discharge, 216 patients (4.21%) went to nursing homes, 153 (2.99%) to rehabilitation, and 115 (2.25%) to long-term care. The STS risk of mortality score was significantly positively associated with discharge status (p < 0.001). Patients with 1%, 2%, 3%, 4%, and 5% STS risk of mortality had 11.25%, 22.10%, 29.45%, 35.00%, and 38.50% probability, respectively, of not being discharged home. When the STS risk of mortality was 5%, the risk of not being discharged home was 47.9% for off-pump patients and 38.10% for on-pump patients. CONCLUSIONS: STS risk score is strongly associated with CABG discharge status. Patients with a risk score exceeding 2 are at high risk (>22%) of not being discharged home. This risk should be discussed when treatment decisions are being made.

Combined congenitally bicuspid aortic valve and mitral valve prolapse causing pure regurgitation.

Described herein is a patient with a purely regurgitant congenitally bicuspid aortic valve and a purely regurgitant prolapsing mitral valve. Although it is well established that the bicuspid aortic valve is a congenital anomaly, it is less well appreciated that mitral valve prolapse is almost certainly also a congenital anomaly. The two occurring in the same patient provides support that mitral valve prolapse is also a congenital anomaly.

Necropsy findings early after transcatheter aortic valve implantation for aortic stenosis.

Although transcatheter aortic valve implantation has been available for 10 years, reports of cardiovascular morphologic studies after the procedure are virtually nonexistent. The investigators describe such findings in 2 patients, both 86 years of age, who died early (hours or several days) after transcatheter aortic valve implantation. Although the prosthesis in each was seated well, and each of the 3 calcified cusps of the native aortic valves was well compressed to the wall of the aorta, thus providing a good bioprosthetic orifice, the ostium of the dominant right coronary artery in each was obliterated by the native right aortic valve cusp. Atherosclerotic plaques in the common iliac artery led to a major complication in 1 patient, who later died of hemorrhagic stroke. The other patient developed fatal cardiac tamponade secondary to perforation of the right ventricular wall by a pacemaker catheter.

Established preoperative risk factors do not predict long-term survival in isolated coronary artery bypass grafting patients.

BACKGROUND: Use of isolated coronary artery bypass grafting (CABG) is expected to increase as the population ages. Short-term adverse outcomes models and their application to the decision-making process have greatly increased the safety and effectiveness of CABG. However, similar tools addressing long-term survival have not been developed. We examined the effect of the preoperative risk factors included in short-term outcomes models on long-term survival in patients who survive CABG. METHODS: A Cox survival model considering preoperative risk factors identified by The Society of Thoracic Surgeons was developed for 8,529 consecutive patients who underwent isolated CABG between January 1, 1997, and August 31, 2010, at Baylor University Medical Center (Dallas, Texas) and were alive 30-days post-CABG. RESULTS: There were 2,388 (27.9%) deaths during follow-up (≤14 years). Unadjusted survival was 83.8% and 65% at 5 and 10 years, respectively. The Cox model showed that most established preoperative risk factors were significantly associated with survival. Their effect was minimal, however; the variation explained by their cumulative effect in predicting survival was 16.8% (R2=0.168). CONCLUSIONS: Established operative risk factors may not be good predictors of long-term post-CABG survival. Late mortality may be attributable to many causes, not necessarily related to patients' cardiovascular and general health at the time of operation. Discussions with cardiothoracic surgeons and long-term shared decision making with primary care physicians/cardiologists should therefore not focus solely on patients' preoperative risk profile but should also emphasize the importance of preventing/controlling other diseases through a healthy lifestyle and compliance with disease management protocols.

Mechanism and severity of mitral regurgitation by transesophageal echocardiography in patients referred for percutaneous valve repair.

Percutaneous mitral valve repair with the MitraClip has been shown to decrease mitral regurgitation (MR) severity, left ventricular volumes, and functional class in patients with severe (3+ or 4+) MR. Determination of which patients are optimal candidates for MitraClip therapy versus surgery has not been rigorously evaluated. Transesophageal echocardiography was prospectively performed in 113 consecutive patients referred for potential MitraClip therapy under the REALISM continued access registry. MR severity was assessed quantitatively in all patients. Mitral valve anatomy and feasibility of MitraClip placement were assessed by transesophageal echocardiography and clinical parameters. MR was degenerative (mitral valve prolapse) in 60 patients (53%), functional (anatomically normal) in 44 (39%), and thickened with restricted motion (Carpentier IIIB classification) in 9 (8%). MR was mild in 19 patients (17%), moderate in 27 (24%), and severe (3 to 4+) in 67 (59%) by Transesophageal echocardiography. MitraClip placement was performed in only 17 of 113 patients (15%); all were successful. Surgical mitral valve repair was performed in 25 patients (22%), mitral valve replacement in 12 (11%). Most patients (59 of 113, 52%) were treated medically, usually because MR was not severe enough to warrant intervention. In conclusion, most patients referred for MitraClip therapy do not have severe enough MR to warrant intervention. Of those with clinical need for intervention, surgery is more often recommended for anatomic or clinical reasons. Three-dimensional transesophageal echocardiography with quantitative assessment of MR severity is helpful in evaluating these patients.

Comparing long-term survival between patients undergoing off-pump and on-pump coronary artery bypass graft operations.

BACKGROUND: As the population of the United States and Western Europe ages, the number of patients undergoing isolated coronary artery bypass grafting (CABG) for revascularization can be expected to increase. This study investigated long-term survival in patients undergoing off-pump vs on-pump CABG. METHODS: Survival was assessed in 8081 consecutive patients who underwent isolated CABG (732 received off-pump) between January 1, 1997, and December 31, 2008. A propensity-adjusted model controlling for preoperative risk factors identified by the Society of Thoracic Surgeons and other preoperative clinical and nonclinical details was used to assess adjusted long-term mortality differences between off-pump and on-pump CABG. RESULTS: Ten-year unadjusted survival was 54.7% (95% confidence interval, 47.2% to 61.6%) in off-pump CABG patients and 62.3% (95% confidence interval 60.9% to 63.8%) in on-pump CABG patients. The log-rank test (p=0.012) indicated a significantly higher risk of death in off-pump CABG patients. After adjustment, the risk of death remained significantly higher in the off-pump CABG patients (hazard ratio, 1.18; 95% confidence interval, 1.02 to 1.38). The adjusted association regarding off-pump learning curve and survival was assessed separately and was not statistically significant (p=0.774), further validating our findings regarding off-pump CABG. CONCLUSIONS: After controlling for preoperative severity of disease and other possible confounders, the risk of long-term mortality in patients undergoing off-pump CABG is significantly higher than in those undergoing on-pump CABG. For multivessel coronary disease, on-pump CABG might be preferable to off-pump CABG given that it may achieve a more complete and durable revascularization.

New-onset postoperative atrial fibrillation and long-term survival after aortic valve replacement surgery.

BACKGROUND: Atrial fibrillation (AF) is recognized as a common complication of open cardiac surgery, occurring in up to 65% of patients. The advancing age and increasing risk profile of patients receiving aortic valve replacement (AVR) surgery is expected to raise incidence of new-onset postoperative AF resulting in potentially higher risk of adverse outcomes. In the early postoperative course, new-onset post-AVR AF is considered relatively easy to treat and is believed to have little impact on patients' long-term outcome. However, the effect of new-onset post-AVR AF on long-term survival is unclear. METHODS: Survival was assessed in 1,039 consecutive patients without preoperative AF who underwent AVR with or without simultaneous coronary artery bypass graft at Baylor University Medical Center, Dallas, Texas between January 1, 1997 and December 31, 2006. RESULTS: Ten-year unadjusted survival was 50.8% for patients with new-onset postoperative AF and 59.4% for patients without. A propensity-adjusted model controlling for risk factors identified by the Society of Thoracic Surgeons and other clinical-nonclinical details was used to investigate the association between new-onset AF post-AVR and survival. After adjustment, new-onset AF post-AVR was significantly associated with increased risk of death (hazard ratio: 1.48; 95% confidence interval 1.12 to 1.96). CONCLUSIONS: This study provides evidence that new-onset post-AVR AF is significantly associated with increased long-term risk of mortality independent of the preoperative severity of disease. After controlling for a comprehensive array of risk factors associated with post-AVR adverse outcomes, risk of long-term mortality in patients who developed new-onset post-AVR AF was 48% higher than in patients without it.

New-onset postoperative atrial fibrillation after isolated coronary artery bypass graft surgery and long-term survival.

BACKGROUND: The advancing age and generally increasing risk profile of patients receiving isolated coronary artery bypass graft (CABG) surgery is expected to raise incidence of new-onset postoperative atrial fibrillation (AFIB) resulting in potentially higher risk of adverse outcomes. In the early postoperative course, new-onset post-CABG AFIB is considered relatively easy to treat and is believed to have little impact on patients' long-term outcome. However, little has been done to determine the effect of new-onset post-CABG AFIB on long-term survival, and this relationship is unclear. METHODS AND RESULTS: Survival was assessed in a cohort of 6899 consecutive patients without preoperative AFIB who underwent isolated CABG at Baylor University Medical Center, Dallas, Tex, between January 1, 1997 and December 31, 2006; patients who died during CABG were excluded. Ten-year unadjusted survival was 52.3% (48.4%, 56.0%) for patients with new-onset postoperative AFIB and 69.4% (67.3%, 71.4%) for patients without it. A propensity-adjusted model controlling for risk factors identified by the Society of Thoracic Surgeons and other clinical/nonclinical details was used to investigate the association between new-onset AFIB post-CABG and long-term survival. After adjustment, new-onset AFIB post-CABG was significantly associated (hazard ratio, 1.29; 95% CI, 1.16, 1.45) with increased risk of death. CONCLUSIONS: This study provides evidence that new-onset post-CABG AFIB is significantly associated with increased long-term risk of mortality independent of patient preoperative severity. After controlling for a comprehensive array of risk factors associated with post-CABG adverse outcomes, risk of long-term mortality in patients that developed new-onset post-CABG AFIB was 29% higher than in patients without it.