Contemporary experience with the Commando procedure for anterior mitral anular calcification.

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

Infective Endocarditis in Patients Addicted to Injected Opioid Drugs.

BACKGROUND: Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death. OBJECTIVES: The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors. METHODS: From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE). RESULTS: Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse. CONCLUSIONS: Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.

Predictors and outcomes of discharge to long-term acute care facilities after cardiac surgery.

OBJECTIVE: An increasing number of patients with significant comorbidities present for complex cardiac surgery, with a subgroup requiring discharge to long-term acute care facilities. We aim to examine predictors and mortality after discharge to a long-term acute care facility. METHODS: From January 1, 2015, to April 30, 2021, all adult cardiac surgeries were queried and patients discharged to long-term acute care facilities were identified. Baseline characteristics, procedures, and in-hospital complications were compared between long-term acute care facility and non-long-term acute care facility discharges. Random forest analysis was conducted to establish predictors of discharge to long-term acute care facilities. Kaplan-Meier survival analysis was used to determine probability of survival over 7 years. Multivariate regression modeling was used to establish predictors of death after long-term acute care facility discharge. RESULTS: Of 29,884 patients undergoing cardiac surgery, 324 (1.1%) were discharged to a long-term acute care facility. The long-term acute care facility group had higher rates of urgent/emergency operation (54% vs 23%; 10% vs 3%, P < .001) and longer mean cardiopulmonary bypass (167 vs 110 minutes, P < .001). By random forest analysis, emergency/urgent status, longer cardiopulmonary bypass duration, redo surgery, endocarditis, and history of dialysis were the most predictive of discharge to a long-term acute care facility. Although the non-long-term acute care facility group demonstrated greater than 95% survival at 6 months, Kaplan-Meier survival analysis showed 28% 6-month mortality in the long-term acute care facility cohort. Random forest analysis demonstrated that chronic lung disease and postoperative respiratory complications were significant predictors of death at 6 months after discharge to a long-term acute care facility. CONCLUSIONS: Patients with chronic lung and kidney disease undergoing prolonged procedures are at higher risk to be discharged to long-term acute care facilities after surgery with worse survival. Efforts to minimize postoperative respiratory complications may reduce mortality after discharge to long-term acute care facilities.

Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report.

Bilateral transverse thoracosternotomy, or "clamshell" thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.

Incidence, Risk Factors, and Outcomes Associated With Permanent Pacemaker Implantation Following Tricuspid Valve Surgery.

BACKGROUND: Data regarding permanent pacemaker (PPM) implantation following tricuspid valve surgery (TVS) are limited. We sought to evaluate its incidence, risk factors, and outcomes. METHODS AND RESULTS: Medicare beneficiaries who underwent TVS from 2013 to 2020 were identified. Patients who underwent TVS for endocarditis were excluded. The primary exposure of interest was new PPM after TVS. Outcomes included all-cause mortality and readmission with endocarditis or heart failure on follow-up. Among the 13 294 patients who underwent TVS, 2518 (18.9%) required PPM placement. Risk factors included female sex (relative risk [RR], 1.26 [95% CI, 1.17-1.36], P<0.0001), prior sternotomy (RR, 1.12 [95% CI, 1.02-1.23], P=0.02), preoperative second-degree heart block (RR, 2.20 [95% CI, 1.81-2.69], P<0.0001), right bundle-branch block (RR, 1.21 [95% CI, 1.03-1.41], P=0.019), bifascicular block (RR, 1.43 [95% CI, 1.06-1.93], P=0.02), and prior malignancy (RR, 1.23 [95% CI, 1.01-1.49], P=0.04). Tricuspid valve (TV) replacement was associated with a significantly higher risk of PPM implantation when compared with TV repair (RR, 3.20 [95% CI, 2.16-4.75], P<0.0001). After a median follow-up of 3.1 years, mortality was not different in patients who received PPM compared with patients who did not (hazard ratio [HR], 1.02 [95% CI, 0.93-1.12], P=0.7). PPM placement was not associated with a higher risk of endocarditis but was associated with a higher risk of heart failure readmission (HR, 1.28 [95% CI, 1.14-1.43], P<0.001). CONCLUSIONS: PPM implantation frequently occurs after TVS, notably in female patients and patients undergoing TV replacement. Although mortality is not increased, it is associated with higher rates of heart failure rehospitalization.

Arterial Hyperoxemia During Cardiopulmonary Bypass Was Not Associated With Worse Postoperative Pulmonary Function: A Retrospective Cohort Study.

BACKGROUND: Arterial hyperoxemia may cause end-organ damage secondary to the increased formation of free oxygen radicals. The clinical evidence on postoperative lung toxicity from arterial hyperoxemia during cardiopulmonary bypass (CPB) is scarce, and the effect of arterial partial pressure of oxygen (Pa o2 ) during cardiac surgery on lung injury has been underinvestigated. Thus, we aimed to examine the relationship between Pa o2 during CPB and postoperative lung injury. Secondarily, we examined the relationship between Pa o2 and global (lactate), and regional tissue malperfusion (acute kidney injury). We further explored the association with regional tissue malperfusion by examining markers of cardiac (troponin) and liver injury (bilirubin). METHODS: This was a retrospective cohort study including patients who underwent elective cardiac surgeries (coronary artery bypass, valve, aortic, or combined) requiring CPB between April 2015 and December 2021 at a large quaternary medical center. The primary outcome was postoperative lung function defined as the ratio of Pa o2 to fractional inspired oxygen concentration (F io2 ); P/F ratio 6 hours following surgery or before extubation. The association between CPB in-line sample monitor Pa o2 and primary, secondary, and exploratory outcomes was evaluated using linear or logistic regression models adjusting for available baseline confounders. RESULTS: A total of 9141 patients met inclusion and exclusion criteria, and 8429 (92.2%) patients had complete baseline variables available and were included in the analysis. The mean age of the sample was 64 (SD = 13), and 68% were men (n = 6208). The time-weighted average (TWA) of in-line sample monitor Pa o2 during CPB was weakly positively associated with the postoperative P/F ratio. With a 100-unit increase in Pa o2 , the estimated increase in postoperative P/F ratio was 4.61 (95% CI, 0.71-8.50; P = .02). Our secondary analysis showed no significant association between Pa o2 with peak lactate 6 hours post CPB (geometric mean ratio [GMR], 1.01; 98.3% CI, 0.98-1.03; P = .55), average lactate 6 hours post CPB (GMR, 1.00; 98.3% CI, 0.97-1.03; P = .93), or acute kidney injury by Kidney Disease Improving Global Outcomes (KDIGO) criteria (odds ratio, 0.91; 98.3% CI, 0.75-1.10; P = .23). CONCLUSIONS: Our investigation found no clinically significant association between Pa o2 during CPB and postoperative lung function. Similarly, there was no association between Pa o2 during CPB and lactate levels, postoperative renal function, or other exploratory outcomes.

Re-operation for a detached left coronary button from an aortic root conduit causing a large retro-sternal pseudoaneurysm.

Our goal was to replace the previous composite graft with a bioprosthesis. The approach involved axillary artery and femoral vein cannulation and cardiopulmonary bypass with moderate hypothermia for re-entry of the chest and deep hypothermia with circulatory arrest to get control of and to clamp the aorta when entering the pseudoaneurysm. The myocardial protection strategy was general cooling and retrograde cardioplegia through direct coronary sinus cannulation and antegrade cardioplegia in the coronary ostia when possible. After the pseudoaneurysm was entered, the graft was divided in the middle, and the distal end was dissected out under circulatory arrest sufficiently to allow clamping and to resume systemic circulation. The graft was not dissected out beyond the previous anastomosis. Under another period of circulatory arrest, the distal graft was removed to the mid-arch, and a new graft was attached with a hemiarch anastomosis. Then the root was dissected out, and both coronary ostia were mobilized. The mechanical aortic valve and previous graft material were explanted. A new bioprosthetic valved conduit was used to replace the aortic root, and the coronary buttons were re-implanted directly in the new graft.

What determines outcomes in multivalve reoperations? Effect of patient and surgical complexity.

OBJECTIVE: Patient characteristics, risks, and outcomes associated with reoperative multivalve cardiac surgery are poorly characterized. Effect of patient variables and surgical components of each reoperation were evaluated with regard to operative mortality. METHODS: From January 2008 to January 2022, 2324 patients with previous cardiac surgery underwent 2352 reoperations involving repair or replacement of multiple cardiac valves at Cleveland Clinic. Mean age was 66 ± 14 years. Number of surgical components representing surgical complexity (valve procedures, aortic surgery, coronary artery bypass grafting, and atrial fibrillation procedures) ranged from 2 to 6. Random forest for imbalanced data was used to identify risk factors for operative mortality. RESULTS: Surgery was elective in 1327 (56%), urgent in 1006 (43%), and emergency in 19 (0.8%). First-time reoperations were performed in 1796 (76%) and 556 (24%) had 2 or more previous operations. Isolated multivalve operations comprised 54% (1265) of cases; 1087 incorporated additional surgical components. Two valves were operated on in 80% (1889) of cases, 3 in 20% (461), and 4 in 0.09% (2). Operative mortality was 4.2% (98 out of 2352), with 1.7% (12 out of 704) for elective, isolated multivalve reoperations. For each added surgical component, operative mortality incrementally increased, from 2.4% for 2 components (24 out of 1009) to 17% for ≥5 (5 out of 30). Predictors of operative mortality included coronary artery bypass grafting, surgical urgency, cardiac, renal dysfunction, peripheral artery disease, New York Heart Association functional class, and anemia. CONCLUSIONS: Elective, isolated reoperative multivalve surgery can be performed with low mortality. Surgical complexity coupled with key physiologic factors can be used to inform surgical risk and decision making.

Radiation Exposure in Extracorporeal Life Support.

Extracorporeal membrane oxygenation (ECMO) exposes patients to multiple radiologic studies. We hypothesized ECMO patients endure radiation exposure in excess of the International Commission of Radiological Protection (ICRP) recommendations of cumulative effective dose (CED, >20 mSv and 5-year cumulative limit of CED >100 mSv). We conducted a retrospective observational study in an academic medical center between January 2016 and December 2018 involving adult admissions (N = 306) on ECMO. Ionizing radiation was calculated from reference values to determine CED. Approximately 9.4% (N = 29) patients accrued CED >50 mSv and 4.5% (N = 14) accrued CED >100 mSv during ECMO. Over the entire hospitalization, 28% (N = 85) accrued >50 mSv and 14.7% (N = 45) accrued CED >100 mSv. Median CED during ECMO was 2.3 mSv (IQR, -0.82 to 8.1 mSv), and the entire hospitalization was 17.4 mSv (IQR, -4.5 to 56.6 mSv). Thirteen percent of the median CED accrued during hospitalization could be attributed to ECMO. Longer hospitalization was associated with a higher CED (50 days [IQR, -25 to 76 days] in CED >50 vs. 19 days [IQR, -10 to 32 days] in CED <50). Computer tomography (CT) scans and interventional radiology (IR) procedures contributed to 43.8% and 44.86%, respectively, of CED accrued on ECMO and 52.2% and 37.1% of CED accumulated during the whole hospitalization. Guidelines aimed at mitigating radiation exposure are urgently needed.

Concomitant tricuspid valve repair for mild-moderate tricuspid regurgitation patients undergoing mitral valve surgery? A meta-analysis and meta-regression.

The development of tricuspid regurgitation (TR) is a common complication of mitral valve disease. Although severe TR is usually operated on at the same time of mitral valve surgery (MVS), controversies remain regarding whether mild to moderate TR patients should be operated. Concomitant tricuspid valve repair with MVS for mild-moderate TR patients. Electronic databases were searched from inception to November 20, 2022 to include any observational or randomized controlled trials (RCT) that compare concomitant tricuspid repair with MVS versus MVS alone. Mantel-Haenszel method was used to pool study estimates and calculate odds ratios (OR) with 95% confidence intervals (CI). A total of 9813 patients from 25 studies were included. Regarding primary outcomes, concomitant repair group had significantly lower 30 days mortality (OR: 0.66; 95% CI 0.45 to 0.96), all-cause mortality-based on RCTs- (OR: 0.40; 95% CI 0.22 to 0.71), cardiovascular mortality (OR: 0.53; 95% CI: 0.33 to 0.86) and heart failure hospitalizations (OR: 0.41; 95% CI: 0.26 to 0.63). However, was associated with higher permanent pacemaker implantation rates (OR: 2.09; 95% CI: 1.45 to 3.00). There were no significant differences in terms of secondary outcomes: tricuspid valve reinterventions, stroke and acute kidney injury. Furthermore, repair group showed lower risk for TR progression degrees (OR 0.08; 95% CI 0.05 to 0.16) and decreased mean of TR progression (MD -1.85; 95% CI -1.92 to -1.77). Concomitant tricuspid valve repair in mild or moderate TR at time of MVS appears to reduce not only 30 days but also long-term all-cause and cardiovascular mortality weighed against the increased risk of pacemaker implantation.

First Case of Cupravidus paculus Infection in a Lung Transplant Recipient: A Case Report.

Cupravidus paculus is a rare Gram-negative bacterium that can cause a wide range of severe infections, largely in immunocompromised patients. It is a ubiquitous organism found in natural and man-made environments and in the hospital. Herein, we present the first case of C. paculus infection in a lung transplant recipient, which required prolonged antibiotic therapy to achieve complete clearance. Additionally, we review the existing literature on the clinical and microbiological profile of C. paculus, along with previously documented cases of clinical infections. Our case highlights the potential sources of C. paculus infections, the importance of appropriate disinfection protocols for medical devices, and the need for antibiotic sensitivities to guide treatment.

Right heart failure and patient selection for isolated tricuspid valve surgery.

OBJECTIVE: To characterize patients with right heart failure undergoing isolated tricuspid valve surgery, focusing on right heart morphology and function. PATIENTS AND METHODS: From January 2007 to January 2014, 62 patients underwent isolated tricuspid valve surgery. Forty-five patients (73%) had undergone previous heart operations. Right heart morphology and function variables were measured de novo from stored echocardiographic images, and clinical and hemodynamic data were extracted from patient registries and records. Cluster analysis was performed and outcomes assessed. RESULTS: On average, the right ventricle was dilated (diastolic area 32 cm2), but its function was preserved (free-wall strain -17% ± 5.8%) and right heart failure manifestations were moderate, with 40 (65%) having congested neck veins, 35 (56%) dependent edema, and 15 (24%) ascites. Average model for end-stage liver disease with sodium score was 11 ± 4.4, but individual values varied widely. Tricuspid valve variables split patients into 2 equal clusters: those with functional tricuspid regurgitation (TR) and those with structural TR. These groups had similar right ventricular function, but the functional TR group had worse right ventricular morphology and more severe manifestations of right heart failure, including greater model for end-stage liver disease with sodium scores (12 ± 44 vs 9.1 ± 3.9; P = .008). Both groups survived operation with low morbidity, but patients with functional TR had worse long-term survival, 48% versus 73% at 10 years after surgery. CONCLUSIONS: The cluster analysis of patients with right heart failure undergoing isolated tricuspid valve surgery separated functional and structural tricuspid valve disease. Good early outcomes suggest expanding criteria for tricuspid valve surgery and earlier intervention for functional TR with right heart failure.

Successful treatment of pulmonary mucormycosis (Lichtheimia spp.) in a post-partum patient with COVID-19 ARDS requiring extra-corporeal membrane oxygenation using salvage therapy.

Case Summary: A 31-year-old female presented to a regional hospital at 27 weeks pregnant and was found to have COVID-19 ARDS. She underwent intubation and caesarian section for worsening hypoxia and non-reassuring fetal heart tones. Hypoxemia was refractory to proning requiring ECMO and transfer to a tertiary care center. Admission chest radiography showed a new right lower lobe cavitating lesion with computed tomography scan revealing a large multi-loculated cavity in the right lung and extensive bilateral ground-glass opacities. The patient was started on amphotericin and posaconazole, with final respiratory cultures growing Lichtheimia spp. Source control was discussed via possible open thoracostomy, but medical management alone was continued. Total ECMO support was 3 weeks. At the time of discharge to acute rehab, 1 month of amphotericin and posaconazole had been completed, with continuation of posaconazole. At last update, she had been discharged from rehab and was back home with her infant. Conclusion: Pulmonary mucormycosis, even in the non-ECLS population, carries a high mortality. Treatment in pulmonary disease with surgery improves mortality but is not always feasible. Salvage therapy with extended course antifungal medications may be an option for those not amendable.

A 73-Year-Old Woman with a Fall.

A 73-Year-Old Woman with a FallA 73-year-old woman who had a cholecystectomy 2 months ago presented for evaluation after a fall. How do you approach the evaluation, and what is your differential diagnosis?

Imaging and haemodynamic parameters associated with clinical outcomes following isolated tricuspid valve surgery.

INTRODUCTION: Isolated tricuspid valve surgery (TVS) may be associated with high morbidity and mortality. The aim of this study was to investigate the association of preoperative imaging and haemodynamic data derived from echocardiography (ECHO), cardiac magnetic resonance (CMR) and right heart catheterisation (RHC) with postoperative outcomes following TVS. METHODS: In a retrospective cohort study, patients who underwent isolated TVS at our institution between 2012 and 2020 were screened and followed up to 1 year. We only included those who had all three tests before surgery: ECHO, CMR and RHC. Patients with congenital heart disease, infective endocarditis and those who underwent concomitant valve or pericardial surgery were excluded. The primary outcome was a composite of mortality and congestive heart failure at 1 year. Time-to-event analyses at 1 year and Cox proportional hazards regression analyses were performed. RESULTS: A total of 60 patients were included (mean age of 60±14 years, 63% women), of whom 67% underwent TV repair. The primary outcome occurred in 16 patients (27%) with a 1-year mortality of 7%. It was associated with ECHO-derived right ventricular (RV) free wall strain and RHC-derived RV systolic and diastolic as well as mean pulmonary pressures. On multivariable Cox regression analysis, only RV systolic and diastolic pressures were significantly associated with the primary outcome at 1 year (HRs=5.9 and 3.4, respectively, p<0.05). CONCLUSION: Baseline invasive haemodynamic assessment could have a strong association with clinical outcomes and help risk-stratify patients undergoing isolated TVS.

Valve-Preserving Root Reimplantation Combined with Arch Procedure: Optimizing Patient Selection.

Objective: Patients with thoracic aortic disease commonly present with concomitant multisegment pathology. We describe the patient population, analyze outcomes, and define the patient selection strategy for valve-preserving aortic root reimplantation (VPARR) combined with the arch procedure. Methods: From 2008 to 2018, 98 patients underwent VPARR combined with the aortic arch procedure (hemi-arch, 50% [n = 49, limited repair]; total arch, 50% [n = 49, complete repair] including 39 with elephant trunk). Indications for surgery were aneurysmal disease (61%) and aortic dissection (39%). The median follow-up was 17 months (IQR, 8 to 60 months). Results: There were no operative deaths or paraplegia, and 5 patients underwent re-exploration for bleeding. During follow-up, 2 patients required aortic valve replacement for severe aortic insufficiency at 1 and 5 years, and 4 patients died. In the limited repair group, 1 patient underwent reintervention for aortic arch replacement, whereas 4 patients underwent planned intervention (1 endovascular and 3 open thoracoabdominal aortic repair). In the complete repair group, 23 patients underwent planned intervention (15 endovascular and 8 open thoracoabdominal repair). Conclusions: Single-stage, complete, proximal aortic repair including VPARR combined with total aortic arch replacement is as safe and feasible to perform as limited arch repair and facilitates further intervention in carefully selected patients with diffuse aortic pathology at centers of expertise.