Treatment Adherence Rates and Long-Term Mortality in a Quaternary Multidisciplinary Heart Team: An Observational Cohort.

BACKGROUND: A multidisciplinary heart team (HT) approach to patients with complex coronary artery disease has a class IB recommendation, yet there are limited data on adherence to HT treatment recommendations and long-term clinical follow-up. The objective of this study was to assess adherence rates to HT recommendations and assess long-term mortality rates among patients with complex CAD. METHODS AND RESULTS: Six hundred eighty-four sequential HT cases for complex coronary artery disease from January 2015 to May 2017 were reviewed. After excluding cases with significant comorbid valve disease, baseline characteristics were compared based on HT treatment recommendations: optimal medical therapy, percutaneous coronary intervention, and coronary artery bypass grafting. Adherence rates were manually extracted, and 5-year mortality rates were obtained from the Michigan Death Registry. Seventy-two percent of 405 included patients were men (mean age 66±11 years), with high rates of medical comorbidities. Estimated surgical risk scores were lowest in the coronary artery bypass grafting group. Optimal medical therapy was recommended in 138 patients (34%), percutaneous coronary intervention in 95 (23%), and coronary artery bypass grafting in 172 (42%). Adherence to HT recommendations across groups was high (96%) and did not differ between treatment groups. Over 5 years of follow-up, there were 119 deaths, resulting in a cumulative mortality rate of 29%. CONCLUSIONS: In the largest HT cohort in the United States to date, high rates of adherence to HT recommendations were observed among high-risk patients with coronary artery disease. High rates of adherence to HT recommendations were observed irrespective of treatment group recommendation, suggesting that HT recommendations were individualized and acceptable to both patients and physicians alike.

Four-year follow-up of outcomes of the hybrid epicardial-endocardial ablation: A single-center experience.

BACKGROUND: The CONVERGE trial demonstrated that hybrid epicardial and endocardial ablation was more effective than catheter ablation for the treatment of persistent atrial fibrillation (AF) at 1 year. Long-term real-world outcome data are scarce. OBJECTIVE: We described a single-center experience by evaluating the long-term effectiveness and safety of hybrid epicardial-endocardial ablation. METHODS: This is a retrospective single-center study. Patients were followed up to 4 years. The primary end point was the rate of AF recurrence up to 4 years postablation. Secondary end points included reduction in antiarrhythmic therapy use, the effect of the ligament of Marshall removal, epicardial posterior wall, 3-dimensional mapping during epicardial ablation, and left atrial appendage exclusion as adjunct intraoperative interventions for AF recurrence. RESULTS: Of the 170 patients, 86.5% had persistent AF and 13.5% had long-standing persistent AF. AF-free survival was 87.6% at 1 year, 76.9% at 2 years, 70.4% at 3 years, and 59.3% at 4 years. Antiarrhythmic drug use was 87.6% at baseline and reduced to 21%, 20.6%, 18%, and 14.1% at year 1, 2, 3, and 4, respectively (P < .01 for all). Three-dimensional epicardial mapping showed a significant reduction in combined recurrence from 42% to 25% over 4 years of follow-up (P = .023). Ligament of Marshall and left atrial appendage exclusion showed numerical reduction in AF recurrence from 35% to 26% (P = .49) and from 44% to 30% (P = .07). CONCLUSION: The hybrid convergent procedure reduces AF recurrence and the need for antiarrhythmic drugs and, while maintaining a good safety profile, for the treatment of persistent and long-standing persistent AF.

Contemporary outcomes of surgical aortic valve replacement in patients referred for a transcatheter approach.

OBJECTIVES: The purpose of this study is to examine which patients referred to our structural valve clinic for potential transcatheter aortic valve replacement (TAVR) are receiving surgical aortic valve replacement (SAVR) whether due to unsuitable anatomy for TAVR versus other reasons. METHODS: Individuals referred for TAVR from January 2019 to March 2022, who ultimately underwent SAVR were examined, retrospectively. Patients were divided into 2 surgical groups: TAVR was technically unsuitable (SAVR-TU) and those in which TAVR was technically feasible (SAVR-TF). RESULTS: 215 patients referred for TAVR underwent SAVR with 61 (28.4%) patients in the SAVR-TU group and 154 (71.6%) in the SAVR-TF group. The SAVR-TU group were more commonly female (52.5% vs 23.4%, p < 0.0001), had a higher incidence of stroke at baseline (9.8% vs 2.0%, p = 0.017) were frailer (5-m gait 5.2 s vs 4.7 s, p = 0.0035), and had a higher Society of Thoracic Surgery risk score (2.2 vs 1.7, p = 0.04). In the SAVR-TU group, unsuitability for TAVR was due to inadequate aortic root anatomy (86.9%), and poor peripheral access (6.6%). In the SAVR-TF group, the most common reasons for SAVR referral were concomitant coronary artery disease (42.9%), bicuspid aortic valve disease (16.9%), and concomitant aortic aneurysm (10.4%). Overall, in-hospital mortality was 1.4% with no difference between both groups. One-year survival was 96.7%. CONCLUSION: Despite a higher trend of aortic stenosis being treated with TAVR, higher risk patients unsuitable for TAVR can have SAVR with excellent outcomes. Moreover, patients with AS and concomitant other pathology should be evaluated for cardiac surgery.

del Nido versus blood cardioplegia in cardiac surgery: A multicenter analysis of over 40,000 patients.

OBJECTIVES: The use of del Nido cardioplegia in adult cardiac surgery is rising in popularity. The objective of this large multicenter study was to evaluate the use and associated outcomes of del Nido versus blood cardioplegia in adult cardiac surgery. METHODS: Patients undergoing coronary artery bypass grafting (CABG) and/or valve (mitral, aortic), and/or nondescending thoracic aortic surgery (July 2014 to March 2022) across 39 centers were extracted from the Perfusion Measures and Outcomes registry. Patients were stratified by cardioplegia type for unadjusted analysis and multivariable mixed-effects models were used for risk adjustment. RESULTS: Of 44,175 patients, 42.5% used del Nido, with use increasing 48% over time. Overall, the del Nido group had shorter median crossclamp time (74 minutes vs 87 minutes, P < .001) and lower median peak intraoperative glucose levels (161 mg/dL vs 180 mg/dL, P < .001). Use of del Nido was not associated with operative mortality (adjusted odds ratio [ORadj], 1.16; P = .075) nor major morbidity (ORadj, 1.05; P = .25). Findings for valve cases were similar, except crossclamp time differences were variable by type of valve procedure. Within the CABG subgroup there was a trend toward increased operative mortality with del Nido (ORadj, 1.24; P = .069), whereas the risk of renal failure approaches statistical significance in the aortic subgroup (ORadj, 1.54; P = .056). CONCLUSIONS: In this large, multicenter study, the use of del Nido was associated with variable crossclamp time differences, lower intraoperative glucose levels, and no significant difference in major morbidity or mortality. Efficiency benefits of del Nido may be limited in valve cases, whereas outcomes in CABG and aortic cases warrant further study.

Randomized Feasibility Trial of Prophylactic Radiofrequency Ablation to Prevent Atrial Fibrillation after Cardiac Surgery.

OBJECTIVE: Evaluate the feasibility of prophylactic radiofrequency isolation of the pulmonary veins, with left atrial appendage amputation, to reduce the incidence of postoperative atrial fibrillation (POAF) after cardiac surgery in patients aged 70 and older. METHODS: The Federal Food and Drug Administration granted an investigational device exemption to utilize a bipolar radiofrequency clamp for prophylactic pulmonary vein isolation in a limited, feasibility trial. Sixty-two patients without prior dysrhythmias, were prospectively randomized to undergo either their index cardiac surgical procedure, or bilateral pulmonary vein isolation and left atrial appendage amputation during their cardiac operation. The primary outcome was occurrence of in-hospital POAF. Subjects were on 24-hour telemetry until discharge. Dysrhythmias, any episode of atrial fibrillation > 30 seconds, were confirmed by electrophysiologists blinded to the study. RESULTS: Sixty patients, mean age 75 years and mean CHA2DS2-VASc score 4, were analyzed. Thirty-one patients randomized to control and twenty-nine to the treatment group. Majority of cases in each group were isolated CABG. No perioperative complications related to the treatment procedure, need for permanent pacemaker, or mortality occurred. The in-hospital incidence of POAF was 55% (17/31) in the control group and 7% (2/29) in the treatment group. (p<0.001) The control group had a significantly higher requirement for antiarrhythmic medications at discharge, 45% (14/31) vs 7% (2/29) in the treatment group (p<0.001). CONCLUSIONS: Prophylactic radiofrequency isolation of the pulmonary veins with left atrial appendage amputation, during the primary cardiac surgical operation, reduced the incidence of POAF in patients 70 years and older with no history of atrial arrhythmias.

Del Nido Cardioplegia in Ascending Aortic Surgery.

Del Nido cardioplegia offers equivalent myocardial protection and clinical outcomes to blood cardioplegia in adult isolated CABG and valve patients, but the safety and efficacy of del Nido in complex cases with prolonged aortic cross-clamp times is still unknown. 443 patients at our center underwent replacement of the ascending aorta using either del Nido (n = 182) or blood (n = 261) cardioplegia. Two surgeons used del Nido exclusively and 6 used blood exclusively over the study period. Propensity matching of preoperative characteristics yielded 172 well matched pairs. Emergency and reoperative cases were included. Clinical data were extracted from our local database. Troponin levels were drawn at 12 hours postop in all patients. Rates of perioperative mortality (4.7% vs 5.2%), stroke (5.8% vs 7.0%), renal failure (11.6% vs 12.2%), atrial fibrillation (36.0% vs 31.4%), intra-aortic balloon pump insertion (2.3% vs1.2%), and extra corporeal membrane oxygenation use (4.7% vs 4.1%) did not differ between blood and del Nido groups. Postop Troponin T levels were 0.50[0.35, 0.86] ng/mL and 0.40[0.20, 0.70] ng/mL for blood and del Nido, respectively (P < 0.0001). Postop echocardiography was available in 333 of 344 (96.8%) patients, and there was no difference in change in EF from pre- to postop between blood 0.0[-6.0, 5.0]% and del Nido 0.0 [-6.0, 3.5]% (P = 0.201). Subgroup analysis of patients with aortic cross-clamp time greater than 180 minutes (blood = 77, del Nido = 27) revealed no difference in troponins, ejection fraction, or clinical outcomes. Five-year survival was 85.9[76.8, 91.7]% and 79.8[71.2, 86.1]% for blood and del Nido, respectively (P = 0.151). In ascending aortic surgery with prolonged operative times, no differences were observed in myocardial protection or clinical outcomes with the use of del Nido cardioplegia compared to blood cardioplegia.

Contemporary Management of Ischemic Mitral Regurgitation at Coronary Artery Bypass Grafting.

BACKGROUND: Recent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase. METHODS: Patients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score-matched analyses were used to compare patients with and without mitral intervention. RESULTS: A total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; Ptrend = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; Ptrend = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5). CONCLUSIONS: Consistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity.

Efficacy of del Nido cardioplegia in adult cardiac procedures with prolonged aortic crossclamp time.

OBJECTIVE: Equivalent myocardial protection and clinical outcomes have been shown with the use of del Nido cardioplegia (DC) compared with blood cardioplegia (BC) in adult isolated coronary artery bypass grafting and valve patients. However, its safety and efficacy in cardiac procedures with aortic crossclamp times >90 minutes is still unknown. METHODS: From May 2014 to September 2019, 2506 adult patients at our center underwent cardiac surgery requiring prolonged aortic crossclamp time defined as 90 minutes or longer. Myocardial protection was achieved with BC in 1955 patients and DC in 551 patients. Two surgeons used DC exclusively and 5 used blood exclusively over the study period. BC was delivered anterograde and retrograde whereas DC was delivered anterograde only. Propensity score matching of several preoperative characteristics, including primary cardiac pathology, yielded 526 well matched pairs. Emergency and reoperative cases were included. Troponin T levels were drawn at 12 hours postoperative in all patients. Clinical data were extracted from our local Society of Thoracic Surgeons database. Subgroup analyses were performed on the basis of crossclamp time stratification. RESULTS: For the propensity score-matched cohort, the median crossclamp time was longer in the BC compared with the DC group (114 [interquartile range (IQR), 100-145] minutes for DC vs 153 [IQR, 122-200] minutes for BC; P < .0001) whereas intraoperative peak glucose was higher with BC (173 [IQR, 147-200] g/dL for DC vs 197 [IQR, 171-228] g/dL for BC; P < .001). In addition, perioperative mortality (3.4% vs 3.0%; P = .7273), stroke (3.2% vs 2.1%; P = .2504), renal failure (6.5% vs 4.6%; P = .1767), atrial fibrillation (34% vs 31.4%, P = .3575), intra-aortic balloon pump use (5.3% vs 4.6%, P = .5694), and extracorporeal membrane oxygenation use (3.0% vs 2.9%, P = .8596) did not differ between DC and BC. Postoperative troponin T levels were 0.53 (IQR, 0.30-0.96) ng/mL and 0.62 (IQR, 0.38-1.07) ng/mL for DC and BC, respectively (P = .0024). Subgroup analysis revealed higher troponin T levels with DC for crossclamp times between 150 and 180 minutes. Survival rates at 1, 2, and 5 years were 93.3%, 91.1%, and 78.7% for DC and 94.5%, 91.8%, and 81.5% for BC, respectively (P = .5140). CONCLUSIONS: In adult cardiac surgical procedures with aortic crossclamp times >90 minutes, comparable myocardial protection, perioperative mortality and morbidity, and distant survival were observed with the use of DC compared with BC. Higher troponin levels were seen in DC patients with crossclamp times between 150 and 180 minutes, but this was not associated with increased mortality.

Freestyle Aortic Bioprostheses in Patients 60 Years old and Younger.

Evaluate outcomes of the Freestyle stentless aortic bioprosthesis in patients 60 years old and younger. All patients, 60 years old and younger, between January 1, 1998 to December 31, 2015 who underwent implantation of a Freestyle aortic valve at a single institution were reviewed. Medical records and telephone interviews were utilized for data collection. 515 patients were identified with an average age of 51.3 years. Mean follow up was 11.1 years. 225 full root replacements and 290 subcoronary implants were performed. Overall survival, including patients with concomitant procedures, at 15 years was 63.7% (95% CI 58.3-68.5). Isolated subcoronary implants (58%,167/290) had a 15-year survival of 71.6% (95% CI 62.6-78.7) vs 78.4% (95% CI 69.7, 84.9) for isolated root replacements (63%,141/225) which was not statistically significant (P = 0.397). No significant difference in operative SVD at 15 years occurred between full root replacements 37.6% (95% CI 27.2-50.2) vs subcoronary implants 39.4% (95% CI31.1, 49.0). 110 patients required reoperation solely for intrinsic SVD. 93% (102/110) failed due to aortic insufficiency. Of reoperative interventions for SVD, 37% (41/110) of patients required urgent reoperation and 4.5% (5/110) required emergent reoperation. Pseudoaneurysms developed in six of the full root replacements. Freestyle aortic valves have a high rate of acute failure requiring urgent or emergent reintervention in patients 60 years old and younger. This has led our group to shift practice away from their implantation.

Long-term outcomes of etiology specific annuloplasty ring repair of ischemic mitral regurgitation.

BACKGROUND: Reductive annuloplasty repair of ischemic mitral regurgitation (IMR) is associated with high rates of recurrent MR, which may be improved with etiology-specific annuloplasty rings. METHODS: From October 2005 to May 2015, 128 consecutive patients underwent repair of IMR with the GeoForm ring. Clinical data was extracted from our local Society of Thoracic Surgeons database and electronic medical records. Mortality data was obtained from the Michigan State Social Security Death Index. RESULTS: The average age of patients was 65±11 years with mean pre-op left ventricular ejection fraction (LVEF) of 30%±10% and MR grade of 3.1±0.9 (0-4+). Thirty-day mortality was 4.7%, rate of renal failure 7.9%, rate of atrial fibrillation 27.3%, and no strokes were observed. Of the surviving patients, 89% (109/122) had a follow-up echocardiogram beyond 1 month with a mean echocardiographic follow-up of 59±39 months. LVEF improved from 30%±10% to 38%±14%, P<0.001) while end-diastolic (5.9±0.0 to 5.3±0.9 cm, P<0.001) and end-systolic (5.0±1.0 to 4.4±1.1 cm, P<0.001) left ventricular (LV) diameters decreased, as compared to pre-operative values. Seven patients were found to have recurrent moderate or greater IMR in follow-up to 10 years with three being due to ring dehiscence. One-, 5-, and 10-year freedom from recurrent moderate or severe IMR was 98%, 94%, and 80% respectively. One-, 5-, and 10-year survival was 91%, 77%, and 44%, respectively. CONCLUSIONS: Overall, etiology-specific ring repair of IMR was associated with low rates of recurrent MR on long-term follow-up, coupled with significant LV reverse remodeling and improvement in ejection fraction.

Del Nido cardioplegia in isolated adult coronary artery bypass surgery.

BACKGROUND: Del Nido cardioplegia (DC) offers prolonged single-dose myocardial protection in pediatric cardiac surgery. We set out to evaluate the efficacy of DC in adult patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: From January 2012 to October 2017, 851 consecutive isolated CABG surgeries were performed by 2 study surgeons at our center with blood cardioplegia (BC, n = 350), used from January 2012 to April 2014, and DC (n = 501), used from May 2014 to October 2017. Propensity matching was used to yield 325 well-matched pairs. Clinical data were extracted from our local Society of Thoracic Surgeons database and mortality data from the Michigan State Social Security Death Index. RESULTS: Single-dose administration was used in 83% (417/501) of patients receiving DC. In propensity-matched groups, postoperative median troponin T levels (0.28 [0.16-0.59] ng/mL vs 0.46 [0.27-0.81] ng/mL; P < .01) were lower for patients receiving DC, and no difference in ejection fraction on postoperative echocardiography was observed (54 ± 12% and 53 ± 13% for BC and DC, respectively; P = .36). Perioperative outcomes were similar except for greater rate of atrial fibrillation (33% vs 23%; P = .01) in the DC group. Subgroup analyses revealed equivalent myocardial protection and clinical outcomes in patients with age ≥75 years, left ventricular ejection fraction ≤35%, left main disease, or Society of Thoracic Surgeons score ≥2.5%. Four-year survival did not differ between patients undergoing BC or DC. CONCLUSIONS: The current study revealed noninferior myocardial protection and clinical outcomes with DC versus BC in both routine and greater-risk patients undergoing isolated CABG. DC demonstrated the feasibility of single-dose administration for isolated CABG surgery. Larger randomized studies are needed to further explore the safety and efficacy of DC in adult cardiac surgery with longer crossclamp times.

Long-Term Outcomes of Mosaic Versus Perimount Mitral Replacements: 17-Year Follow-Up of 940 Implants.

BACKGROUND: The objective of this study was to compare long-term outcomes of Mosaic (Medtronic, Minneapolis, MN) porcine mitral valves to Carpentier-Edwards (Edwards Lifesciences, Irving, CA) bovine pericardial mitral valves. METHODS: From 2001 through 2017 at a single institution, 940 patients received a mitral bioprosthesis, of which 463 (49.3%) were porcine and 477 (50.7%) were bovine pericardial. Retrospective review of the procedure and the postoperative clinical course, including echocardiography, through August 2018 were analyzed. All consecutive mitral valve replacements over the study period were included. Follow-up was 99% (929 patients) complete for a total of 6045 patient-years (mean, 6.4 ± 4.5 years). A propensity-matched cohort of 802 mitral bioprosthesis was used for outcome analyses. RESULTS: Operative mortality of the 940 patients was 5.4% (n = 51) and incidence of postoperative stroke was 2.1% (n = 20). Overall survival of the propensity-matched patients at 10 and 15 years was 49.7% (95% confidence interval [CI] 45.5%-53.7%) and 23.3% (95% CI 17.9%-29.3%), respectively. Survival at 15 years was 24.0% (95% CI 18.0%-30.5%) for porcine and 16.5% (95% CI 5.5%-32.6%) for bovine implants, which was not significantly different (P = .67). Overall cumulative incidence for reoperative structural valve deterioration at 15 years was 7.9% (95% CI 4.7%-12.3%) for porcine valves versus 13.2% (95% CI 8.1%-19.5%) for pericardial valves (P < .001). For patients age younger than 65 years, structural valve deterioration at 15 years was 15.8% (95% CI 7.4%-27.0%) versus 30.2% (95% CI 15.1%-46.8%) for porcine and pericardial valves, respectively (P = .009). Overall average time to reoperation for structural valve deterioration for porcine valves was 11.1 ± 2.3 years vs 6.8 ± 2.3 years for bovine pericardial valves (P < .001). CONCLUSIONS: In long-term follow-up, of patients younger than 65 years of age undergoing mitral valve replacement, bovine pericardial valves experienced earlier and more frequent structural valve deterioration than porcine valves.

Use of an Automated Suture Fastening Device in Minimally Invasive Aortic Valve Replacement.

BACKGROUND: Minimally invasive aortic valve replacement (mAVR) is gaining clinical acceptance; however, it is associated with increased operative times because of the limited surgical field and access. The Cor-Knot (CK; LSI Solutions, Victor, NY) is an automated fastening device designed to facilitate suture fastening, but clinical data in mAVR are lacking. METHODS: From May 2014 to February 2017, 92 patients underwent mAVR at Spectrum Health in Grand Rapids, Michigan; 39 valves were secured with manually tied sutures, and 53 valves were entirely secured with the CK device. Preoperative characteristics and 30-day outcomes data were extracted from the local The Society of Thoracic Surgeons database and the patients' electronic medical records. Survival data were obtained from the Michigan State Social Security Death Index. RESULTS: No significant differences in preoperative characteristics were noted between the two groups. Aortic cross-clamp time (72 ± 12 minutes vs 82 ± 15 minutes; p = 0.001) was significantly shorter with CK. There was no difference in the rate of postoperative mortality (0% vs 0%), stroke (0% vs 1.9%), atrial fibrillation (28% vs 33%), renal failure (0% vs 3.8%), or pacemaker implantation (5.1% vs 5.7%) between patients with manually tied sutures and patients with sutures fastened with the CK. Valve function on postoperative echocardiography and 1-year patient survival rates were similar. CONCLUSIONS: In mAVR, the CK device was associated with reduced aortic cross-clamp time while providing equivalent clinical outcomes. Larger studies are needed to confirm the efficacy, safety, and cost-effectiveness of the CK device in minimally invasive aortic valve surgery.

Single-dose del Nido Cardioplegia in Minimally Invasive Aortic Valve Surgery.

del Nido cardioplegia (DC) offers prolonged cardiac protection with single-dose administration and has been shown to be safe in adult CABG surgery. We set out to evaluate the efficacy of cardiac protection and clinical outcomes of DC versus standard blood cardioplegia (BC) in minimally invasive aortic valve surgery. From August 2011 to May 2016, 178 patients underwent minimally invasive aortic valve replacement (mini-AVR) with BC (n = 101) or DC (n = 77). Ministernotomy or right minithoracotomy was utilized for surgical access. Clinical patient characteristics and data were extracted from our local Society of Thoracic Surgeons (STS) database and the electronic medical record. Patients were propensity matched for age, gender, body mass index, valve size and type, STS score, surgical access, preop creatinine, diabetes, and chronic obstructive pulmonary disease, yielding 63 well-matched pairs. There was no difference in patient age, preoperative creatinine, body mass index, diabetes, chronic obstructive pulmonary disease, or STS score between BC and DC before or after propensity matching. BC patients received both anterograde and retrograde cardioplegias in multiple doses, whereas DC was delivered almost entirely anterograde with 95% of the patients (73/77) receiving a single dose only. DC was associated with decreased cardiopulmonary bypass time (108 ± 24 vs 135 ± 43 minutes, P = 0.001) and aortic cross-clamp time (80 ± 16 vs 102 ± 30 min, P = 0.001) and maximal glucose levels during cardiopulmonary bypass (165 ± 39 vs 202 ± 49 mg/dL, P = 0.001), whereas troponin T level did not differ between DC and BC (0.3 ± 0.29 vs 0.44 ± 1.7 ng/mL, P = 0.7). Preoperative ejection fraction did not change in either BC (64% ± 12% vs 61% ± 10%, P = 0.09) or DC (58% ± 14% vs 57% ± 14%, P = 0.4) after AVR. In minimally invasive AVR surgery, DC provided equivalent myocardial protection and clinical outcomes to BC while simplifying cardioprotective regimen and reducing aortic cross-clamp time. DC was associated with lower cardiopulmonary bypass glucose levels and demonstrated the feasibility of a single-dose administration.

WITHDRAWN: Single-dose del Nido cardioplegia in minimally invasive aortic valve surgery.

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A propensity matched analysis of outcomes and long term survival in stented versus stentless valves.

BACKGROUND: To compare the perioperative and long term survival after aortic valve replacement using stentless versus stented valves in a large cohort of patients grouped using propensity score matching. METHODS: From 1991 to 2012, 4,563 patients underwent aortic valve replacement with stentless and stented valves at our institution. Propensity score matching identified 444 pairs using 13 independent variables: incidence of operation, smoking status, renal failure, hypertension, diabetes, peripheral vascular disease, cerebrovascular disease, chronic lung disease, ejection fraction, gender, age, valve status, and use of coronary artery bypass graft. Data were collected from our Society of Thoracic Surgeons database and the Social Security Death Index. Groups were compared using univariate and Kaplan-Meier analysis. RESULTS: The two groups demonstrated no significant differences for the 13 matching variables and the majority of 30-day outcomes (p > 0.05). The stented valve group showed a higher incidence of postoperative bleeding (3.6% vs 1.1%, p = 0.015), but a lower incidence of stroke (0.9% vs. 2.9%, p = 0.028). One, five, and 10-year survival was 95.0, 80.7, and 52.8% for stented and 93.2, 80.5, and 51.3% for stentless valves. Overall survival did not differ significantly between the two groups (p = 0.641). CONCLUSIONS: Stentless and stented valves had identical 30-day outcomes except for a higher postoperative incidence of bleeding and a lower incidence of stroke in the stented group. There was no significant difference in long term survival between valve types. Both valves may be used for aortic valve replacement with low morbidity and excellent long term survival.

Outcomes in patients undergoing complex cardiac repairs with cross clamp times over 300 minutes.

BACKGROUND: Long cross clamp times have been associated with poor clinical outcomes, yet some patients require extremely long ischemic times to repair complex surgical problems. The purpose of this study was to examine short and mid-term survival and to identify risk factors for mortality and morbidity in patients with cross clamp times greater than or equal to 300 min. METHODS: Review of our institution's Society of Thoracic Surgeons database identified 202 patients who underwent surgical procedures necessitating aortic cross clamp times 300 min or greater between 2001 and 2012. Short-term (30-day) clinical outcomes were derived from this database and survival was assessed utilizing the Social Security Death Index. Univariate and multivariate analyses were used to determine the relationship between independent variables and mortality and postoperative outcomes. RESULTS: The average age of the patients was 69.5 ± 10.6 (mean ± standard deviation) years and the mean ejection fraction was 52 ± 12 %. 70.3 % of patients were male. Mean cross clamp time was 346 ± 45 min, and total bypass time was 421 ± 70 min. Thirty-day mortality was 12.4 %. The incidence of bleeding and stroke were 6.4 % and 4.0 % respectively. Prolonged ventilation occurred in 26.7 % of patients, and incidence of renal failure was 10.4 %. One, three, five, and seven year survival of the patients who survived the first 30 days post-surgery was 91.9 %, 83.2 %, 75.6 % and 65.7 % respectively. Proportional hazards analysis determined that the statistically significant hazard ratios for mid-term mortality for female gender, age, and prolonged postoperative ventilation were 2.11, 1.04 and 2.72, respectively (p < 0.05 for each). CONCLUSIONS: Cardiac procedures requiring extremely long ischemic times have significant early mortality and morbidity. However, mid-term survival in the patients who survive is good. Decision-making regarding operability in complex cases should allow for long ischemic times.

Propensity Matched Analysis of del Nido Cardioplegia in Adult Coronary Artery Bypass Grafting: Initial Experience With 100 Consecutive Patients.

BACKGROUND: Del Nido cardioplegia (DC) offers prolonged cardiac protection with single-dose administration and has had a long safety record in pediatric cardiac surgery. However, its application in the adult population has thus far been limited. We evaluated the efficacy of cardiac protection and clinical outcomes of DC vs blood cardioplegia (BC) in adult coronary artery bypass graft (CABG) patients. METHODS: Clinical outcomes of 100 consecutive isolated CABG patients who received DC (May to September 2014) were compared with the previous 100 consecutive isolated CABG patients receiving BC (December 2013 to April 2014). Propensity matching yielded 82 pairs. The same surgeons operated on all patients. Clinical patient characteristics and data were extracted from our local The Society of Thoracic Surgeons database and the electronic medical record. RESULTS: Preoperative characteristics were similar between BC and DC patients before and after propensity matching. BC patients received anterograde and retrograde cardioplegia, whereas DC was delivered anterograde, with 92 of 100 patients receiving a single dose only. Inotropic support upon arrival to the recovery unit did not differ between BC and DC (0.28 ± 0.11 vs 0.27 ± 0.11 µg/kg/min milrinone [p = 0.8] and 0.05 ± 0.03 vs 0.05 ± 0.03 µg/kg/min norepinephrine [p = 0.7]), nor did postoperative troponin T levels (0.56 ± 0.48 vs 0.70 ± 1.27 ng/mL; p = 0.3). The peak intraoperative glucose level was higher in BC (209.8 ± 40.4 mg/dL) than in DC (161.4 ± 42.3 mg/dL) patients (p < 0.001). No patients died in either group, and the postoperative incidence of atrial fibrillation, stroke, reoperation for bleeding, and prolonged intubation did not differ between the groups before and after matching. There was also no difference in the postoperative ejection fraction between the groups (0.51 ± 0.13 vs 0.47 ± 0.13 for BC and DC, respectively; p = 0.17). CONCLUSIONS: In our initial experience, DC provided equivalent myocardial protection and clinical outcomes to BC in adult isolated CABG patients. DC was associated with lower cardiopulmonary bypass glucose levels than BC and demonstrated the feasibility of single-dose administration for routine coronary operations.

Aortic valve replacement in octogenarians with prior cardiac surgery.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been advocated for very elderly patients with aortic stenosis, and prior cardiac surgery as a less invasive treatment option. Although surgical aortic valve replacement (AVR) is safe and effective in selected elderly patients, the perioperative and mid-term outcomes of AVR in very elderly with prior cardiac surgery are unknown. METHODS: The Society of Thoracic Surgeons (STS) Database at our center enrolled 3,735 patients after AVR since 1997. In this time interval, we identified 61 patients 80 years and older who underwent AVR for severe AS or failed aortic bioprosthesis after having prior cardiac surgery. All clinical parameters were derived from the STS database. Follow-up mortality was assessed using the Social Security Death Index. RESULTS: The average age of the patients was 83 ± 2 years, 77% were male, and 75% underwent an isolated coronary artery bypass graft (CABG) as their first cardiac procedure. The mean ejection fraction was 0.53 ± 0.13. The CABG was performed concurrently in 49% of patients at the time of redo sternotomy and AVR. Stented bioprosthesis was implanted in 61% of patients and stentless in 39%. Perioperative mortality was 1.6% (1 of 61). One, 3, 5, and 7 year survival rates were 85%, 69%, 63%, and 43%, respectively. Patients with AVR only had similar survival to patients who underwent concomitant AVR and CABG. Type of aortic prosthesis did not influence postoperative survival. CONCLUSIONS: In selected patients over the age of 80 with history of prior cardiac surgery, AVR can be performed safely with very good mid-term outcomes. Age alone should not be exclusion criteria for surgical AVR in octogenarians with prior cardiac surgery.

Five-year real world outcomes of GeoForm ring implantation in patients with ischemic mitral regurgitation.

BACKGROUND: Reductive ring annuloplasty represents the current standard surgical therapy for ischemic mitral regurgitation (IMR); however, the clinical results have been suboptimal. Etiology-specific prostheses such as the GeoForm annuloplasty ring have been designed to better address the annular and subvalvular perturbations associated with IMR. However, clinical experience is limited, and mid-term results are lacking. METHODS: We reviewed the clinical outcomes of 86 patients who had undergone implantation of a GeoForm ring at our center from 2005 to 2011. Perioperative mortality and clinical parameters were derived from The Society of Thoracic Surgeons database. Follow-up survival was assessed using the Social Security Death Index. Surviving patients were interviewed by telephone for valve-specific follow-up data and to complete the Medical Outcomes Study, short-form, 36-item, quality-of-life questionnaire. RESULTS: The mean grade of IMR preoperatively was 3.1±0.8 (range, 1-4+), 0.2±0.4 in the immediate postoperative period, and 0.7±0.7 at the last mean follow-up point of 41 months; only 2 patients developed ≥2+IMR during the follow-up period, for a 5-year freedom from recurrent 2+ IMR of 86%. The mean left ventricular end-diastolic and end-systolic diameters decreased from before to after surgery from 6.0±0.0 cm to 5.3±09 cm and 5.0±0.9 cm to 4.3±1.1 cm, respectively (P<.001). Perioperative mortality was 5.8% (5 of 86), and 1-, 3-, and 5-year survival was 87%, 81%, and 75%, respectively. At the last follow-up point, 80% of patients were in New York Heart Association class I and II, and their quality of life was equal to, or better than, age-matched controls from the general population. CONCLUSIONS: Implantation of the GeoForm ring offers very good control of IMR, with low rate of recurrent IMR at mid-term follow-up. The use of this prosthesis was associated with good perioperative mortality, mid-term survival, and quality of life.