Mini Aortic Valve Replacement Converted to Bentall Procedure Secondary to Chronic Type A Aortic Dissection.

In our case, a 46-year-old female with severe aortic insufficiency presented for minimally invasive aortic valve replacement. The patient was taken to the operating room, where transesophageal echocardiography showed severe aortic regurgitation with prolapse of the non-coronary cusp. The patient was placed on a cardiopulmonary bypass machine with peripheral cannulation. The aorta was cross-clamped, and an aortotomy was made. Despite multiple attempts, the left main coronary ostium was not visible. A sternotomy was quickly performed, and a newly discovered chronic type A dissection, obscuring the left main coronary artery, was found. Seventeen minutes after the cross-clamp was placed, the left main was transected, and cardioplegia was delivered. The patient then underwent a Bentall procedure with an aortic valve and root replacement.

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement.

BACKGROUND: Nowadays, one of the main goals of aortic valve surgery is to reduce the biological impact, mortality, and complications. It is well-known that long operative times in terms of the extracorporeal circulation, but above all, of the aortic cross-clamp time (ACC), represent a risk factor for mortality in patients undergoing cardiac surgery. In order to shorten the aortic cross-clamp time, many technological improvements, such as sutureless prostheses, have been introduced, but their actual effectiveness has not been proven yet. The aim of this study was to assess the 30-day outcomes of patients undergoing aortic valve replacement surgery, focusing on the ACC length. METHODS: All 3139 patients undergoing aortic valve replacement between January 2013 and July 2022 at our institution were enrolled. The data were retrospectively collected and the baseline characteristics and intraoperative variables were recorded. In order to adjust the results according to the differences in the baseline characteristics, propensity score matching was performed and four groups of 351 patients were obtained based on the first, second, third, and fourth quartile of the ACC time. RESULTS: The patient population included 132 redo surgeries (9.4%) and 61 cases of active endocarditis (4.3%), with an overall median EuroSCORE II of 1.8 (IQR 1.2-3.1). An increase across the groups was observed in terms of the acute kidney failure (p < 0.001) incidence, the number of blood transfusions (p = 0.022), prolonged hospital stays (p < 0.001), the and respiratory failure (p < 0.001) incidence. A p of < 0.1 was found for the 30-day mortality (p = 0.079). The predictors of an early 30-day mortality were standard full sternotomy (OR 2.48, 95% CI 1.14-5.40, p = 0.022), EuroSCORE II (OR 1.10, 95% CI 1.05-1.16, p < 0.001), and a trend for a longer ACC time (Q4 vs. Q1: OR 2.62, 95% CI 0.89-7.68, p = 0.080). CONCLUSIONS: Shortening the operative times resulted in marked improvements of the patients' outcomes. The combined use of minimally invasive approaches and sutureless aortic valve prostheses allows for a lower 30-day events rate. New technologies should be assessed to obtain the best results with the least risk.

Effect of newly developed scissors-attached micro-forceps on the recipient clamp time and occurrence of anastomotic site infarction after bypass surgery for moyamoya disease.

Introduction: This study aimed to examine the effect of newly developed scissors-attached micro-forceps in superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis for moyamoya disease (MMD). Materials and methods: Of 179 consecutive STA-MCA anastomoses on 95 hemispheres of 71 MMD patients at the University of Fukui Hospital between 2009 and 2023, 49 anastomoses on 26 hemispheres of 21 patients were enrolled in this retrospective cohort clinical trial intraoperative indocyanine green video-angiography did not demonstrate bypass patency in three anastomoses in two patients who were excluded. Twenty-one anastomosis in 19 hemispheres of 16 patients were performed using the conventional micro-forceps (conventional group, CG), and 25 anastomoses in 22 hemispheres of 19 patients were performed using scissors-attached micro-forceps (scissors group, SG). A small infarction near the anastomotic site detected using postoperative diffusion-weighted imaging was defined as anastomotic site infarction (ASI). Factors affecting the occurrence of ASI were examined by univariate, logistic regression, and receiver operating curve (ROC) analysis. Results: There were no significant differences in clinical parameters such as age, sex, number of sacrificed branches, number of sacrificed large branches, and number of sutures between the CG and SG. However, the clamp time and occurrence of ASI were significantly lower in the SG than in the CG. Logistic regression analysis revealed that the clamp time was the only significant factor predicting the occurrence of ASI. A receiver operating curve analysis also revealed that the clamp time significantly predicted the occurrence of ASI (area under the curve, 0.875; cutoff value, 33.2 min). Conclusion: The newly developed scissors-attached micro-forceps could significantly reduce the clamp time and occurrence of ASI in STA-MCA anastomosis for MMD.

The Clinical Characteristics of 88 Patients with Total Anomalous Pulmonary Venous Connection and Risk Factors Associated with Early Postoperative Death.

Objective: This study aimed to analyze the outcomes and risk factors of early postoperative death (within 30 days after surgery) in a single-center after repair of total anomalous pulmonary venous connection (TAPVC). Methods: The clinical data of 88 children who had been diagnosed with TAPVC and underwent radical operation in the Shandong Provincial Hospital Affiliated with Shandong First Medical University (China) from January 2015 to July 2021 were retrospectively analyzed. All the patients were divided into the survival group (n = 81) and the death group (n = 7) for the analysis of preoperative and postoperative clinical data. The variables associated with early postoperative death were statistically analyzed to obtain the risk factors for early postoperative death of TAPVC. Results: Of the 88 patients included in this study, 7 (7.95%) patients died early, including 4 supracardiac and 3 infracardiac cases. Recurrent pulmonary vein obstruction occurred in 2 patients after discharged from hospital, and both were intracardiac TAPVC. Delayed death occurred in 2 children, both of which were intracardiac TAPVC cases. According to univariate analysis, the risk factors statistically significantly associated with the early postoperative death included infracardiac type (P = 0.08), preoperative maximum pulmonary vein flow velocity (P = 0.031), preoperative mechanical ventilation (P = 0.043), preoperative maximum pulmonary artery pressure (P = 0.000), intraoperative cardiopulmonary bypass time (P = 0.003) and intraoperative aortic cross-clamp time (P = 0.000). Conclusion: Infracardiac type of TAPVC, preoperative maximum pulmonary vein flow velocity, preoperative mechanical ventilation, preoperative maximum pulmonary artery pressure, intraoperative cardiopulmonary bypass time and aortic cross-clamp time are the risk factors for early postoperative death.

A single-center retrospective study with 1-year follow-up after CEA in patients with severe carotid stenosis with contralateral carotid artery occlusion.

Objective: To analyze the risk factors associated with adverse events after carotid endarterectomy (CEA) in patients with unilateral severe carotid stenosis and contralateral occlusion. Methods: Patients were recruited for CEA between August 2014 and February 2020. CEA was performed under general anesthesia. The carotid clamp time (CCT; long CCT: >20 min) is defined as the period between clamp-on and clamp-off for the stenotic carotid artery. The perioperative factors and postoperative adverse events were recorded. All patients were followed up for 1 year after CEA. Results: Sixty subjects (65.8 ± 7.2 years; 54 males) were included. Patients with adverse events had significantly longer CCT than those without adverse events (60% vs. 40%, P = 0.013). Univariate logistic regression analysis showed that a history of diabetes was significantly associated with adverse events (OR, 0.190; 95% CI, 0.045-0.814; P = 0.025); long CCT was significantly associated with adverse events (OR, 8.500; 95% CI, 1.617-44.682; P = 0.011). After adjusting for confounding factors, including age, sex, BMI, diabetes, PSV, long CCT, non-use of shunt, and history of stroke or TIA, the associations between diabetes and adverse events (OR, 0.113; 95% CI, 0.013-0.959; P = 0.046) were statistically significant; the associations between long CCT and adverse events (OR, 1.301; 95% CI, 1.049-1.613; P = 0.017) were statistically significant. Conclusions: A longer carotid clamp time (>20 min) and a history of diabetes may increase the risk of adverse events in patients with unilateral severe carotid stenosis and contralateral occlusion after CEA. With good preoperative evaluation and intraoperative monitoring, the use of shunts may not be needed intraoperatively in patients with unilateral severe carotid stenosis and contralateral occlusion.

Perioperative junctional ectopic tachycardia associated with congenital heart disease: risk factors and appropriate interventions.

The risk factors and the appropriate interventions for perioperative junctional ectopic tachycardia (JET) in congenital heart disease (CHD) surgery have not been sufficiently investigated despite the severity of this complication. This study aimed to examine the risk factors and interventions for perioperative JET. From 2013 to 2020, 1062 surgeries for CHD (median patient age: 4.3 years, range 0.0-53.0) with or without a cardiopulmonary bypass (CPB) were performed at Hokkaido University, Japan. We investigated the correlation between perioperative JET morbidity factors, such as age, genetic background, CPB/aortic cross-clamp (ACC) time, use of inotropes and dexmedetomidine, STAT score, and laboratory indices. The efficacy of JET therapies was also evaluated. Of the 1062 patients, 86 (8.1%) developed JET. The 30-day mortality was significantly high in JET groups (7% vs. 0.8%). The independent risk factors for JET included heterotaxy syndrome [odds ratio (OR) 4.83; 95% confidence interval (CI) 2.18-10.07], ACC time exceeding 90 min (OR 1.90; CI 1.27-2.39), and the use of 3 or more inotropes (OR 4.11; CI 3.02-5.60). The combination of anti-arrhythmic drugs and a temporary pacemaker was the most effective therapy for intractable JET. Perioperative JET after CHD surgery remains a common cause of mortality. Inotrope use was a risk factor for developing JET overall surgery risk. In short ACC surgeries, heterotaxy syndrome could increase the risk of JET, which could develop even without inotrope use in long ACC surgeries. It is crucial not to delay the treatment in cases with unstable hemodynamics caused by this arrhythmia. It is recommended to reduce numbers not dose of inotropes.

Evaluating proximal clamp site and intraoperative ischemia time among open repair of juxtarenal aneurysms.

BACKGROUND: The proportion of open aneurysm repairs requiring at least a suprarenal clamp has increased in the past few decades, partly owing to preferred endovascular approaches for most patients with infrarenal aneurysms, suggesting that the management of aortic clamp placement has become even more relevant. This study evaluated the association between the proximal clamp site and intraoperative ischemia times with postoperative renal dysfunction and mortality. METHODS: We used the Vascular Quality Initiative to identify all patients undergoing open repairs of elective or symptomatic juxtarenal AAAs from 2004 to 2018 and compared outcomes by clamp site: above one renal artery, above both renal arteries (suprarenal), or above the celiac trunk (supraceliac). Outcomes evaluated included acute kidney injury (AKI), new-onset renal failure requiring renal replacement therapy (RRT), 30-day mortality, and 1-year mortality. We used multilevel logistic regressions and Cox proportional hazards models, clustered at the hospital level, to adjust for confounding. RESULTS: We identified 3976 patients (median age, 71 years; 70% male; 8.2% non-Caucasian), with a median aneurysm diameter of 5.9cm (interquartile range [IQR], 5.4-6.8 cm). Proximal clamp sites were above one renal artery (31%), suprarenal (52%), or supraceliac (17%). The rates of unadjusted outcomes were 20.5% for AKI, 4.1% for new-onset RRT, 4.9% for 30-day mortality, and 8.3% for 1-year mortality. On adjusted analyses, independent of ischemia time, suprarenal clamping relative to clamping above a single renal artery had higher odds of postoperative AKI (adjusted odds ratio [aOR], 1.50; 95% confidence interval; 95% CI, CI, 1.28-1.75), but similar odds for new-onset RRT (aOR, 1.27; 95% CI, 0.79-2.06) and 30-day mortality (aOR, 1.12; 95% CI, 0.79-1.58) and hazards for 1-year mortality (adjusted hazard ratio, 1.12; 95% CI, 0.86-1.45). However, every 10 minutes of prolonged intraoperative ischemia time was associated with an increase in odds or hazards ratio of postoperative AKI by 7% (IQR, 3%-11%), new-onset RRT by 11% (IQR, 4%-17%), 30-day mortality by 11% (IQR, 6%-17%), and 1-year mortality by 7% (IQR, 2%-13%). Patients with more than 40 minutes of ischemia time had notably higher rates of all four outcomes. CONCLUSIONS: Suprarenal clamping relative to clamping above a single renal artery was associated with AKI, but not new-onset RRT or 30-day mortality. However, the intraoperative renal ischemia time was independently associated with all four postoperative outcomes. Although further studies are warranted, our findings suggest that an expeditious proximal anastomosis creation is more important than trying to maintain clamp position below one renal artery, suggesting that suprarenal clamping may be the best strategy for open AAA repair when needed to efficiently perform the proximal anastomosis.

Efficacy of Whole-Blood Del Nido Cardioplegia Compared with Diluted Del Nido Cardioplegia in Coronary Artery Bypass Grafting: A Retrospective Monocentric Analysis of Pakistan.

Background and Objectives: Cardioplegia is one of the most significant components used to protect the myocardium during cardiac surgery. There is a paucity of evidence regarding the utilization of whole-blood Del Nido cardioplegia (WB-DNC) on clinical outcomes in coronary artery bypass grafting (CABG). The purpose of this retrospective cross-sectional study is to compare the effectiveness of diluted (blood to crystalloid; 1:4) Del Nido cardioplegia (DNC) with WB-DNC in patients who underwent elective CABG in a tertiary care hospital in Lahore-Pakistan. Materials and Methods: This was a retrospective descriptive study conducted at the Department of Cardiovascular Surgery, King Edward Medical University, Lahore. The medical database of all consecutive patients admitted from January 2018 to March 2020 and who fulfilled the inclusion criteria were reviewed. Results: Out of 471 patients admitted during the study period, 450 underwent various elective cardiac surgeries. Out of 450, 321 patients (71.33%) were operated on for CABG. Only 234/321 (72.89%) CABG patients fulfilled our inclusion criteria; 120 (51.28%) patients received WB-DNC, while 114 (48.71%) patients were administered with DNC. The former group presented with better clinical outcomes compared with the latter in terms of lesser requirements of inotropic support, low degree of hemodilution, shorter in-hospital stay, improved renal function, and cost-effectiveness. Peak values of serum Troponin-T (Trop-T), creatine kinase-myocardial band (CK-MB) release, and activated clotting time (ACT) were also lower in the WB-DNC group compared with the DNC group. Conclusions: The WB-DNC conferred better myocardial protection, improved early clinical outcomes, and also proved to be economical for patients undergoing elective CABG compared with classical crystalloid cardioplegia solution.

Evaluation of liver function tests after coronary artery bypass surgery (CABG).

BACKGROUND: Coronary artery bypass graft surgery (CABG) may have systemic effects on the body organs as liver. The purpose of present study was to evaluate changes in liver function tests(LFT) after on-pump CABG surgery and risk factors associated with LFT changes.Also, the incidence of acute liver injury after on-pump CABG is determined. METHODS: 385 patients who underwent on-pump CABG surgery were randomly selected.Preoperative and intraoperative risk factors were obtained from their medical records .Postoperative liver function tests at 24, 48 and 72 hours following surgery and discharge time were compared with the preoperative ones. A univariate linear regression analysis was used to assess the possible relationships between these changes and the preoperative and intraoperative risk factors. RESULTS: Statisitcal analysis revealed direct and significant relationship between LFT changes and pump time, aortic cross-clamp clamp time and use of intra-aortic balloon pump(IABP). Also a medical history of previous myocardia infarction was significantly related to the changes in direct bilirubin in the first 48 hours following surgery.level of preoperative left ventricle ejection fraction,smoking and using opium had significant correlation with postoperative AST changes in different days.In 12.9% of patients, the aminotransferases levels increased to more than three folds over normal upper limit but the probability for incidence of acute ischemic liver injury (transient increase in aminotransferases to over 500IU/L) was 0.77%. CONCLUSION: Using techniques to reduce clamp and pump time when possible is important during CABG. Probable liver injuries post inserting IABP should be expected for appropriate monitoring and treatment.

DelNido cardioplegia versus St Thomas cardioplegia solution in double valve replacement: a single centre experience.

INTRODUCTION: The role of cardioplegia cannot be underrated in cardiac surgery. St Thomas solution is the most widely used cardioplegic, but needs repeated dosing. Del Nido solution provides long duration of asystole with adequate protection; but has been used mainly in paediatric patients. This study was aimed to compare Del Nido cardioplegia with St Thomas cardioplegia in adult cardiac surgeries, requiring double valve replacement and compare the outcomes. METHODOLOGY: This retrospective, observational, descriptive study was conducted over a time period spanning from January 2016 to December 2019. A total of 209 patients were included and were separated in two groups DC group (n = 114) and BC group (n = 95) on the basis of cardioplegic solution used. Del Nido solution was administered as single dose. Parameters noted were CPB time, cross clamp time, wean off bypass time, DC shocks given, inotropic support required, ventilation duration, duration of ICU and hospital stay. RESULTS: There was significantly shorter aortic cross clamp time (72.6 ± 10.2 vs. 98.2 ± 9.2), CPB time (92.1 ± 12.3 vs.129.5 ± 11) and wean off bypass time (19.4 ± 5.9 vs. 31.3 ± 7.6) and less requirement of DC shocks (21.2% vs. 65.9%) in DC group. Inotropic requirement in immediate post-operative period was significantly less in DC group both on day of surgery (5.35 ± 1.44 vs. 7.52 ± 3.8) and 24 hours later (3.4 ± 2.12 vs. 2.18 ± 0.72). There was no significant difference in duration of ventilation, ICU and hospital stay. CONCLUSION: Del Nido can be used safely in long duration adult cardiac surgeries and in a single dose with better intra operative and immediate post-operative outcomes as compared to St Thomas solution.

Use of an Aortic Valve Replacement Simulation Model to Understand Hospital Costs and Resource Utilization Associated With Rapid-deployment Valves.

PURPOSE: Aortic stenosis (AS) is the most common cause of adult valvular heart disease. In the past decade, minimally invasive surgery (MIS) to treat AS has gained popularity, especially if performed in combination with rapid deployment valves (RDVs), which shorten cross-clamp time (XCT). This study examines specific outcomes and related costs of aortic valve replacement (AVR) before and after the introduction of RDVs. METHODS: We used the AVR simulator, an economic model developed to correlate cost and resource utilization associated with the adoption of RDVs, to compare 2 scenarios: (1) a current scenario based on standard AVR practices and (2) a proposed scenario based on increasing use of RDVs and an MIS approach. Both scenarios involved 3 subgroups of patients treated with (1) conventional AVR, (2) MIS, and (3) AVR combined with a coronary artery bypass graft. The current scenario (status quo) involved patients treated with traditional biological valves, and the proposed scenario involved patients who underwent implantation with an RDV. The AVR simulator was fed with real-world input data to estimate complication rates and resource consumption in the proposed scenario. Real-world input data for this analysis were obtained from patients diagnosed with a symptomatic heart valve disease between 2015 and 2018, at Clinica-San-Gaudenzio, Novara, Italy. Lastly, the AVR simulator estimated hospital savings by comparing the 2 scenarios. FINDINGS: A total of 132 patients underwent implantation with a traditional biological valve, and 107 were treated with a commercial valve system. The RDV was associated with an increase of 52% of patients undergoing MIS, which generated a 6.1-h reduction of XCT and a total savings of €6695. RDVs also reduced intensive care unit (ICU) and hospital ward length of stay (LOS), leading to savings of €677 and €595 per patient, respectively. Mortality and blood transfusions also improved. The savings for the hospital (related to shorter XCT, hospital ward LOS, and ICU LOS) amounted to €144.111. Our findings were consistent with data gathered from our real-word setting, and results of a sensitivity analysis indicate that our findings were robust across different possible situations. IMPLICATIONS: Switching to RDVs and MIS procedures for AVRs was associated with a reduction of costs related to XCT, hospital ward LOS, and ICU LOS. Hospitals can upload literature- and experience-based clinical and cost values to the AVR simulator to estimate a hospital's performance with the introduction of RDVs compared with standard biological valves. This study was not randomized, so more extensive studies could confirm our results in the future.

Impact of Cardiopulmonary Bypass Time on Postoperative Duration of Mechanical Ventilation in Patients Undergoing Cardiovascular Surgeries: A Systemic Review and Regression of Metadata.

The objective of this study was to detect if cardiopulmonary bypass time duration has any impact on the duration of postoperative mechanical ventilation (MV). The study design was a systematic review and regression analysis of pooled data from previously published studies. All available data are from prospective, retrospective, cross-sectional, and observational studies. Participants included only patient/human studies. There were no interventions. PubMed and Cochrane libraries were searched by utilizing different combinations of keywords: cardiopulmonary bypass and mechanical ventilation. Inclusion criteria were: (1) English articles, (2) studies with an adult population that underwent cardiac surgeries using cardiopulmonary bypass (CPB), (3) studies where the duration of CPB is provided as well as the duration of mechanical ventilation. A regression analysis was performed on the metadata. For the hours of MV, eight studies with 13 data sets (as some studies provide data in subgroups) were included for a total number of 989 subjects. The duration of CPB ranged from 55 to 173.5 minutes for these operations. Postoperative MV hours ranged from nine to 408 hours. Stepwise multiple regression analysis found that cardiopulmonary bypass time (CPBT), age, diabetes, male gender, and ejection fraction correlated with prolonged mechanical ventilation; CPBT was the most strongly correlated variable. Cardiopulmonary bypass time appears to affect clinical outcomes adversely and is associated with prolonged MV. Avoiding CPB or limiting it to a minimum may decrease the days of MV required.

Impact of Cardiopulmonary Bypass and Aorta Cross Clamp Time on the Length of Mechanical Ventilation after Cardiac Surgery among Children: A Saudi Arabian Experience.

Aim Several factors determine the perioperative outcome besides the nature of the congenital heart defect. Prolonged mechanical ventilation (PMV) is a major factor that determines mortality, length of stay (LOS), residual disability, and other functional outcomes. We aim to determine the clinical variables predicting PMV and LOS in hospital, and specifically the impact from the duration of cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC). Method We conducted a retrospective review of the medical records of 413 children consecutively admitted to the Pediatric Cardiac Intensive Care Unit (PCICU) in one year at a single center. We collected demographic information (e.g., age, gender, and weight), perioperative variables, clinical outcomes, length of mechanical ventilation, high-frequency ventilator use, and mortality. We used logistic regression to analyze the data. PMV was defined as mechanical ventilation for longer than seven days. Results A total of 410 records were included in our study. We found no statistically significant association between CPB time and mechanical ventilation days. Forty-seven children had PMV, 362 did not have PMV. We found no statistically significant association between CPB time and mechanical ventilation days after adjusting for covariates. Reanalyzing the data with PMV defined as longer than four days produced the same results. Using a regression model to assess the variables via the least absolute shrinkage and selection operator for feature selection, we found no statistically significant association between ACC time and mechanical ventilation days after adjusting for covariates. Conclusion According to our results, CPB and ACC time are not associated with PMV or prolonged hospital LOS.

Incidence and pattern of Thrombocytopenia in cardiac surgery patients.

OBJECTIVE: To observe the incidence and pattern of thrombocytopenia in cardiac surgery patients. METHODS: This prospective, cohort study was conducted at the Aga Khan University Hospital, Karachi, from November 2014 to April 2015, and comprised adult cardiac patients. Patients with platelet count less than 150,000 x 109/L, history of malignancy, immune thrombocytopenic purpura and on chemo or radiotherapy were excluded. All information including demographics, platelet count, heparin doses, total cardiopulmonary bypass time, cross-clamp time, blood products transfused, any thromboembolic complication and the presence of infection were recorded on a pre-designed proforma. SPSS 19 was used for data analysis.. RESULTS: Of the 177 patients, 130(73.4%) were males and 47(26.6%) were females. The overall mean age was 59.21±10.99 years. Thrombocytopenia was observed in 167(94.4%) patients. Of them, platelet count dropped below 50% in 71(42.5%) patients, 30-50% in 68(40.7%) patients and 20-30% in 28(16.8%) from the baseline value. Regarding pattern of thrombocytopenia, maximum drop in platelet count was noticed on 2nd and 3rd day of surgery. Furthermore, 9(5.3%) patients developed severe thrombocytopenia (<50,000 x 109/L). CONCLUSIONS: The incidence of thrombocytopenia and its severity after cardiac surgery was very high in our study population when compared with western population.

Right ventricular function following surgical aortic valve replacement and transcatheter aortic valve implantation: A cardiovascular MR study.

OBJECTIVE: The response of the RV following treatment of aortic stenosis is poorly defined, reflecting the challenge of accurate RV assessment. Cardiovascular magnetic resonance (CMR) is the established reference for imaging of RV volumes, mass and function. We sought to define the impact of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) upon RV function in patients treated for severe aortic stenosis using CMR. METHODS: A 1.5T CMR scan was performed preoperatively and 6months postoperatively in 112 (56 TAVI, 56 SAVR; 76±8years) high-risk severe symptomatic aortic stenosis patients across two UK cardiothoracic centres. RESULTS: TAVI patients were older (80.4±6.7 vs. 72.8±7.2years, p<0.05) with a higher STS score (2.13±0.73 vs. 5.54±3.41%, p<0.001). At 6months, SAVR was associated with a significant increase in RV end systolic volume (33±10 vs. 37±10ml/m2, p=0.008), and decrease in RV ejection fraction (58±8 vs. 53±8%, p=0.005) and tricuspid annular plane systolic excursion (22±5 vs. 14±3mm, p<0.001). Only 4 (7%) SAVR patients had new RV late gadolinium hyper-enhancement with no new cases seen in the TAVI patients at 6months. Longer surgical cross-clamp time was the only predictor of increased RV end systolic volume at 6months. Post-TAVI, there was no observed change in RV volumes or function. Over a maximum 6.3year follow-up, 18(32%) of TAVI patients and 1(1.7%) of SAVR patients had died (p=0.001). On multivariable Cox analysis, the RV mass at 6m post-TAVI was independently associated with all-cause mortality (HR 1.359, 95% CI 1.108-1.666, p=0.003). CONCLUSIONS: SAVR results in a deterioration in RV systolic volumes and function associated with longer cross-clamp times and is not fully explained by suboptimal RV protection during cardiopulmonary bypass. TAVI had no adverse impact upon RV volumes or function.

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.