Redo Heart Double-Lung Transplant in a Previous Double-Lung Transplant Recipient With Pneumonectomy: A Case Report.

Placing a new donor lung into a postpneumonectomy pleural space has many potential surgical challenges. We report the technical challenges we faced in a case of a 42-year-old man who had initially undergone a double-lung transplant for idiopathic pulmonary arterial hypertension. Unfortunately, his left transplanted lung failed, which required a left pneumonectomy. Eight years later, his remaining right lung failed. He was evaluated and deemed suitable for retransplant. Our report presents the first successful redo heart double-lung transplant surgery preceded by pneumonectomy. There were significant technical intraoperative challenges; however, the procedure was performed successfully with an uneventful postoperative course and follow-up.

Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis.

BACKGROUND: Preoperative anemia is a common comorbidity that often necessitates allogeneic blood transfusion (ABT). As there is a risk associated with blood transfusions, preoperative intravenous iron (IV) has been proposed to increase the hemoglobin to reduce perioperative transfusion; however, randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive. Consequently, a meta-analysis that pools these studies may provide new and clinically useful information. METHODS/DESIGN: Databases of MEDLINE, EMBASE, EBM Reviews; Cochrane-controlled trial registry; Scopus; registries of health technology assessment and clinical trials; Web of Science; ProQuest Dissertations and Theses; Clinicaltrials.gov; and Conference Proceedings Citation Index-Science (CPCI-S) were searched. Also, we screened all the retrieved reference lists. SELECTION CRITERIA: Titles and abstracts were screened for relevance (i.e., relevant, irrelevant, or potentially relevant). Then, we screened full texts of those citations identified as potentially applicable. RESULTS: Our search found 3195 citations and ten RCTs (1039 participants) that met our inclusion criteria. Preoperative IV iron supplementation significantly decreases ABT by 16% (risk ratio (RR): 0.84, 95% confidence interval [CI]: 0.71, 0.99, p = 0.04). In addition, preoperatively, hemoglobin levels increased after receiving IV iron (mean difference [MD] between the study groups: 7.15 g/L, 95% CI: 2.26, 12.04 g/L, p = 0.004) and at follow-up > 4 weeks postoperatively (MD: 6.46 g/L, 95% CI: 3.10, 9.81, p = 0.0002). Iron injection was not associated with increased incidence of non-serious or serious adverse effects across groups (RR: 1.13, 95% CI: 0.78, 1.65, p = 0.52) and (RR: 0.96, 95% CI: 0.44, 2.10, p = 0.92) respectively. CONCLUSIONS: With moderate certainty, due to the high risk of bias in some studies in one or two domains, we found intravenous iron supplementation is associated with a significant decrease in the blood transfusions rate, and modest hemoglobin concentrations rise when injected pre-surgery compared with placebo or oral iron supplementation. However, further full-scale randomized controlled trials with robust methodology are required. In particular, the safety, quality of life, and cost-effectiveness of different intravenous iron preparations require further evaluation.

Predictors of hospital mortality after surgery for ischemic mitral regurgitation: the Toronto General Hospital experience.

BACKGROUND: The benefit of mitral valve repair (MVr) over replacement in patients with severe ischemic mitral regurgitation (IMR) is still controversial. We report our early postoperative outcomes of repair versus replacement. METHODS: Data were collected for patients undergoing first-time mitral valve surgery for severe IMR between 1990 and 2009 (n = 393). Patients who underwent combined procedures for papillary muscle rupture, post-infarction ventricular septal defect, endocarditis, or any previous cardiac surgery were excluded. Preoperative demographics, operative variables, and hospital outcomes were analyzed, and multivariable regression analysis was employed to identify independent predictors of hospital mortality. RESULTS: Valve repair was performed in 42% (n = 164) of patients and replacement in 58% (n = 229). Patients who underwent replacement were older and had a higher prevalence of unstable angina, New York Heart Association Class IV symptoms, preoperative cardiogenic shock, preoperative myocardial infarction, peripheral vascular disease, renal failure, and urgent or emergency surgery (all p < .05). Unadjusted hospital mortality was higher in patients undergoing valve replacement (13% vs. 5%; p = .01). Valve repair was associated with a lower prevalence of postoperative low cardiac output syndrome. Multivariable analysis revealed that age, urgency of operation, and preoperative left ventricular (LV) function were independent predictors of hospital mortality. Importantly, MVr versus replacement was not an independent predictor of hospital mortality. CONCLUSION: Our data did not suggest an early survival benefit to MVr over replacement for IMR. However, age, LV dysfunction, and the need for urgent surgery were independently associated with hospital mortality.

Acceleration-induced acute type A aortic dissection in the sky: 10-year follow-up.

Acute aortic dissection is uncommon, but can turn into a fatal disease if not managed quickly. A 49-year-old male fighter pilot presented to us after sudden excruciating chest pain during a flight at the moment of an acute spiral down action. A contrast-enhanced computed tomography angiography showed Stanford type A aortic dissection that required surgical ascending aorta and hemiarch replacement with uneventful postoperative recovery and 10-year follow-up. Here, we presented the first report of a previously healthy pilot developed acute aortic dissection in the sky. Physicians should be aware of such a case that might happen more common with rapid aviation progress.

Role of preoperative intravenous iron therapy to correct anemia before major surgery: study protocol for systematic review and meta-analysis.

BACKGROUND: Preoperative anemia is a common and potentially serious hematological problem in elective surgery and increases the risk for perioperative red blood cell (RBC) transfusion. Transfusion is associated with postoperative morbidity and mortality. Preoperative intravenous (IV) iron therapy has been proposed as an intervention to reduce perioperative transfusion; however, studies are generally small, limited, and inconclusive. METHODS/DESIGN: We propose performing a systematic review and meta-analysis. We will search MEDLINE, EMBASE, EBM Reviews, Cochrane-controlled trial registry, Scopus, registries of health technology assessment and clinical trials, Web of Science, ProQuest Dissertations and Theses, and conference proceedings in transfusion, hematology, and surgery. We will contact our study drug manufacturer for unpublished trials. Titles and abstracts will be identified and assessed by two reviewers for potential relevance. Eligible studies are: randomized or quasi-randomized clinical trials comparing preoperative administration of IV iron with placebo or standard of care to reduce perioperative blood transfusion in anemic patients undergoing major surgery. Screening, data extraction, and quality appraisal will be conducted independently by two authors. Data will be presented in evidence tables and in meta-analytic forest plots. Primary efficacy outcomes are change in hemoglobin concentration and proportion of patients requiring RBC transfusion. Secondary outcomes include number of units of blood or blood products transfused perioperatively, transfusion-related acute lung injury, neurologic complications, adverse events, postoperative infections, cardiopulmonary complications, intensive care unit (ICU) admission/readmission, length of hospital stay, acute kidney injury, and mortality. Dichotomous outcomes will be reported as pooled relative risks and 95% confidence intervals. Continuous outcomes will be reported using calculated weighted mean differences. Meta-regression will be performed to evaluate the impact of potential confounding variables on study effect estimates. DISCUSSION: Reducing unnecessary RBC transfusions in perioperative medicine is a clinical priority. This involves the identification of patients at risk of receiving transfusions along with blood conservation strategies. Of potential pharmacological blood conservation strategies, IV iron is a compelling intervention to treat preoperative anemia; however, existing data are uncertain. We propose performing a systematic review and meta-analysis evaluating the efficacy and safety of IV iron administration to anemic patients undergoing major surgery to reduce transfusion and perioperative morbidity and mortality. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015016771.

One-year hemodynamic comparison of Perimount Magna with St Jude Epic aortic bioprostheses.

INTRODUCTION: Cardiac surgeons are using more bioprosthetic valves due to the ageing population as well as to improvements that have been made to these implants. We sought to compare the 1-year hemodynamics of two commercially available valves by echocardiographic parameters. MATERIAL AND METHODS: Retrospective review of our institutional database revealed 69 patients who received either Perimount Magna (n = 33) or St Jude Epic (n = 36) valves in the aortic position with no other valve surgery between June 2004 and March 2006. All patients received transthoracic echocardiography at 1 year. Comparisons between groups were made at baseline and at 1-year follow-up. In addition, a pairwise comparison was performed in each patient to determine the change in echocardiographic parameters between baseline and follow-up. RESULTS: Mean implanted valve size was similar (Magna 24.3 ±2.0 mm vs. Epic 24.1 ±2.2 mm). Pre- and intraoperative patient variables were similar between the two groups. There were lower peak and mean pressure gradients in the Magna group, both at discharge and one year after surgery. This correlated with a larger indexed effective orifice area (Magna 0.8 ±0.2 cm(2)/m(2) vs. Epic 0.67 ±0.2 cm(2)/m(2), p = 0.02). In spite of these findings, left ventricular mass regression was not different. CONCLUSIONS: These findings suggest that in a series with relatively low indexed effective orifice areas, the peak and mean gradients obtained were acceptable. More clinical follow-up of these patients is required to assess the true impact of prosthesis patient mismatch.

Double aortic arch presenting in an adult with dysphagia.

Double aortic arch is a congenital anomaly that rarely presents in adults. We describe the case of a 69-year-old male who presented with a double aortic arch, right arch dominant, left arch patent, experiencing progressive dysphagia since childhood.

Valve-sparing root and ascending aorta replacement after heart transplantation.

A 45-year-old female underwent heart transplantation 17 years ago, with a heart from a 15-year-old donor. Recently, she had developed an aneurysm of the donor aortic root and ascending aorta, with severe aortic insufficiency. Two surgical options were considered; retransplantation versus replacement of the aortic root and ascending aorta. A valve-sparing replacement of the aortic root and ascending aortic aneurysm was performed. The donor aorta showed pathologic changes typical of Marfan syndrome. Nineteen months postoperatively, the patient remains in functional class I, with trivial aortic insufficiency.

Decreasing prevalence but increasing importance of left ventricular dysfunction and reoperative surgery in prediction of mortality in coronary artery bypass surgery: trends over 18 years.

OBJECTIVES: The number of patients referred for coronary artery bypass grafting (CABG) has fallen, whereas their risk profile appears to be increasing. We evaluated changes in the predictors of hospital mortality among patients undergoing CABG during a span of 18 years. METHODS: Data were collected prospectively for all patients undergoing isolated CABG (n=23,445) from 1991 to 2008. To examine the effect of time on patients' risk profiles and outcomes, we divided patients into 3 time cohorts (1991-1996, n=8280; 1997-2002, n=9801; 2003-2008, n=5364). We used multivariable logistic regression model to identify predictors of mortality in the entire cohort and in each time cohort. RESULTS: Hospital mortality declined from 2.4% (1991-1996) to 1.2% (2003-2008; P<.0001). Urgent or emergency surgery, left ventricular dysfunction, reoperative CABG, increased age, female gender, hypertension, cardiogenic shock, congestive heart failure, peripheral vascular disease, left main disease, and earlier year of operation (1991-1996) were independent predictors of hospital mortality. The prevalence of most risk factors for mortality increased over the 18-year period of this study. In contrast, the prevalence of severe left ventricular dysfunction and reoperative CABG decreased significantly; however, their associated odds of mortality increased with time. CONCLUSIONS: Whereas the prevalence of most risk factors increased with time, left ventricular dysfunction and reoperative CABG became significantly less common. However, the odds of mortality associated with these 2 predictors increased, indicating that although they occur less commonly, these 2 risk factors paradoxically play an increasingly important role in determining patient outcomes.

Mechanical circulatory support as a bridge to transplant candidacy.

INTRODUCTION: The use of mechanical circulatory support (MCS) in nontransplant eligible candidates remains controversial. Our decision to offer MCS for nontransplant candidates has led to their reevaluation after a period of left ventricular assist device (LVAD) support. METHODS: From 2001 to September 2009, we had 37 patients who received an implantable LVAD, 22 (59%) were not deemed to be transplant eligible at the time of LVAD insertion (bridge to candidacy, BTC group). RESULTS: Fifteen (41%) patients were considered transplant eligible (bridge to transplant, BTT group) at the time of device insertion and received a HeartMate XVE (n = 7), HeartMate 2 (n = 7), or a Novacor LVAS (n = 1). In the BTC group, patients received the HeartMate XVE device (n = 11), HeartMate 2 (n = 5), or the Novacor LVAS (n = 6). The primary criterion for transplant ineligibility was refractory pulmonary hypertension (PH) in 18 patients, 3 patients did not meet our body mass index criteria (>35 kg/m(2)), and 2 patients were dialysis-dependent. Six (27%) BTC patients died on support. Overall, 16/22 patients (73%) were subsequently listed for transplantation, with one listed for combined heart-lung due to refractory PH. Twelve patients (75%) underwent successful heart transplantation. Three patients died during their transplant. Overall posttransplant survival at one year shows lower survival in the BTC group compared to the BTT group (67% vs. 100%, p = 0.05). At two years and three years the survival was lower, but not statistically different (BTC vs. BTT: 67% vs. 90% and 64% vs. 87%, respectively, p = NS). CONCLUSIONS: MCS can successfully convert a large proportion of transplant-ineligible patients into acceptable candidates.

The influence of operative techniques on the outcomes of bicuspid aortic valve disease and aortic dilatation.

BACKGROUND: Bicuspid aortic valve is associated with aortic aneurysm formation that may extend beyond the ascending aorta. METHODS: Between 1979 and 1997, 143 bicuspid aortic valve patients had aortic valve operations with replacement of an aneurysmal ascending aorta: 93 (65%) underwent full root replacement and 50 (35%) underwent separate valve and graft replacement. Distal aortic anastomosis was open in 42 patients (29%) and closed in 101 (71%). Late survival and complications were compared by surgical technique. RESULTS: Patients undergoing full root replacement tended to be younger (mean age 46 +/- 16 vs 59 +/- 13, p < 0.001) and presented with more aortic insufficiency (80% vs 35%, p < 0.001). Three (2.1%) hospital deaths occurred. Event-free survival was 82% (95% confidence interval, 75% to 88%) at 10 years and 41% (95% confidence interval, 11% to 71%) at 20 years. At a median follow-up of 11.5 years, the incidence of new aneurysms and late aortic complications were not significantly different among the procedure groups. Age at the time of operation was the only predictor of late survival (hazard ratio, 1.07; p = 0.007). CONCLUSIONS: Aortic root replacement with distal aortic reconstruction can be achieved with very low operative mortality and excellent long-term outcomes in patients with bicuspid aortic valve and dilated ascending aorta. The type of surgical procedure done in the aortic root and in the distal ascending aorta does not influence late survival, subsequent operation, or aortic complications. This is likely influenced by our patient-specific strategy when replacing the aortic root and distal ascending aorta.

Outcomes of double valve surgery for active infective endocarditis.

OBJECTIVE: In active infective endocarditis the need for operating simultaneously on the aortic and mitral valves is frequent. There are no studies in the literature documenting long-term outcomes of double valve surgery for active endocarditis. METHODS: Ninety patients underwent double valve surgery for active endocarditis over a 26-year period (mean age, 53 +/- 16 years; 71% male patients). Prosthetic endocarditis was seen in 32 patients. Staphylococcus species was isolated in 29%. Forty-six (51%) patients had abscesses. Surgical intervention consisted of valve repair or replacement with limited infection or radical resection, patch reconstruction, and valve replacement for abscesses. Mean follow-up was 5.9 +/- 4.7 years (range, 0-18 years) and was complete. RESULTS: There were 14 (15.6%) in-hospital deaths and 29 (32.2%) late deaths. Overall survival at 5, 7, and 10 years was 68% +/- 5%, 59% +/- 6%, and 49% +/- 6%, respectively, and was reduced in those undergoing operations for prosthetic compared with native endocarditis (7-year survival, 39% +/- 9% vs 71% +/- 7%; P < .001). Freedom from recurrent endocarditis was 84% +/- 5% at 10 years. Freedom from reoperation was 91% +/- 4% at 10 years. Event-free survival at 7 and 10 years was 60% +/- 6% and 47% +/- 7%, respectively. No difference was observed between the native and prosthetic groups for recurrent endocarditis, late reoperation, or event-free survival. Prosthetic endocarditis, increasing age, preoperative shock, and diabetes mellitus were independent predictors of death from all causes. CONCLUSIONS: Double valve surgery for active endocarditis remains technically challenging and associated with significant morbidity and mortality perioperatively and in the longer term. Outcomes are worse in those who have prosthetic valve endocarditis.

Outcomes of surgical intervention for isolated active mitral valve endocarditis.

OBJECTIVE: Although several studies have examined the outcomes of mitral valve repair for infective endocarditis, no studies have documented the long-term outcomes of surgical intervention for active endocarditis confined to the mitral valve. METHODS: One hundred four patients underwent surgical intervention for active infective endocarditis confined to the mitral valve over a 27-year period (mean age, 50 +/- 18 years; 52% female). The infected valve was native in 81 patients, previously repaired 6 patients, and prosthetic in 17 patients. Staphylococcus aureus was the most commonly isolated (32%) source of infection. Twenty-eight (27%) patients had annular abscesses. Surgical intervention consisted of valve repair or replacement for limited infection and radical resection, annular patch reconstruction, and valve replacement for annular abscess. Mean follow-up was 5.6 +/- 4.4 years (range, 0-20 years) and was complete. RESULTS: There were 9 (8.7%) in-hospital deaths and 28 (27%) late deaths. Overall survival at 5, 7, and 10 years was 73% +/- 5%, 68% +/- 5%, and 58% +/- 6%, respectively. At 7 years, freedom from recurrent endocarditis was 89% +/- 4% and freedom from reoperation was 94% +/- 3%. Event-free survival at 7 and 10 years was 60% +/- 6% and 46% +/- 7%, respectively, and was significantly higher in patients with native endocarditis versus those with nonnative endocarditis (ie, prosthetic or previously repaired; 7 years: 63% +/- 7% vs 50% +/- 12%, P < .005). Preoperative shock, S aureus infection, and bioprosthesis insertion were independent predictors of death from all causes. The patients in the bioprosthesis group were older (57 +/- 20 years vs 44 +/- 15 years in the mechanical group and 46 +/- 12 years in the repair group, P = .003). CONCLUSIONS: Surgical intervention for isolated active mitral valve endocarditis remains difficult, with high morbidity and mortality in the long term. Event-free survival is worse in those who have nonnative mitral valve endocarditis.