Limited Distal Repair Results in Low Rates of Distal Events Following Surgery for Acute Type A Aortic Dissection.

To investigate mortality and reoperation rates following limited distal repair after acute type A aortic dissection (ATAAD) at a single medium volume institution. We analyzed all patients that underwent limited distal repair (ascending aortic or hemiarch replacement) following ATAAD between January 1998 and April 2020 at our institution. During the study period, 489 patients underwent ATAAD surgery, of which 457 (94%) underwent limited distal repair with a 30-day mortality of 12.9%. Among 30-day survivors, late follow-up was 97.7% complete with a mean follow-up of 6.0 ± 5.5 years. In all, 50 patients (11%) required a reoperation during the study period at a mean of 3.4 ± 3.4 years after initial repair, with a 30-day mortality of 12%. An aortic reoperation was required in 4.1 (2.0-6.1)%, 10.3 (7.1-13.6)%, 15.1 (10.9-19.4)%, and 18.0 (13.0-22.9)% of patients at 1, 5, 10, and 15 years. A distal reoperation was required in 3.0 (1.2-4.7)%, 8.0 (5.1-10.9)%, 10.3 (6.8-13.8)%, and 12.4 (8.2-16.5)% of patients and 4.4 (2.3-6.4)%, 10.4 (7.1-13.7)%, 13.9 (9.8-18.0)%, and 16.9 (12.0-21.9)% of patents had a distal event at 1, 5, 10, and 15 years, respectively. Limited distal repair with an ascending aortic or hemiarch replacement was associated with acceptable survival and rates of reoperations and distal events. Limited distal repair is a safe and feasible standard approach to ATAAD surgery at a medium-volume center.

Peripheral cannulation and endoaortic balloon occlusion for management of porcelain aorta during cardiac surgery.

Porcelain aorta with extensive calcification of the ascending aorta complicates cardiac surgery and increases perioperative risk. Aortic cannulation and cross-clamping in these patients increase the risk of serious complications including perioperative embolic stroke. Although different techniques have been proposed, surgery in these patients remains a challenge. We present the clinical implications of the porcelain aorta and surgical strategies involving axillary arterial cannulation and endoaortic balloon to allow for the institution of cardiopulmonary bypass and cardioplegic arrest during surgery. The surgery included a redo sternotomy with bioprosthetic mitral valve replacement, tricuspid valve repair with an annuloplasty, and closure of the left atrial appendage. In appropriately selected patients, endoaortic balloon occlusion was a valuable tool to facilitate the safe conduct of an operation. Careful preoperative evaluation and planning by a multidisciplinary team are essential in these cases.

Anomalous inferior vena cava drainage in a patient undergoing cardiac surgery.

Congenital anomalies of the inferior vena cava are rare but if unidentified may create a risk for complications during surgery. In cardiac surgery, identifying such anomalies is crucial as they may alter the normal conduct of cardiopulmonary bypass. Herein, we describe a case of a 78-year-old women with an anomalous inferior vena cava draining into the superior vena cava, who was referred for surgical management of severe mitral regurgitation. We describe the clinical implication of the inferior vena cava anomality and the surgical strategies used to obtain adequate surgical exposure and venous drainage for cardiopulmonary bypass in a patient who underwent a mitral and tricuspid annuloplasty, bi-atrial MAZE procedure and a left atrial appendage closure.

Outcomes of mitral valve re-replacement for bioprosthetic structural valve deterioration.

OBJECTIVES: Reoperation for structural valve deterioration (SVD) of bioprosthetic mitral valves carries a presumed high operative risk, and transcatheter mitral valve-in-valve implantation has emerged as an alternative. However, surgical risk and long-term outcome following mitral valve re-replacement in these patients remain ill-defined. Hence, we sought to evaluate outcomes and long-term survival following surgical mitral valve re-replacement and to identify risk factors for mortality. METHODS: From January 1990 to January 2017, 525 patients underwent surgical mitral valve re-replacement at Cleveland Clinic for bioprosthetic SVD: 133 (25%) isolated operations and 392 (75%) with concomitant procedures. Surgical complications and modes of death were compiled, long-term mortality assessed, and risk factors identified using a multivariable nonproportional hazards model and random forest analysis. RESULTS: SVD was characterized by bioprosthetic regurgitation in 81% (425 out of 525) and stenosis in 44% (231 out of 525). One in-hospital death occurred after isolated valve re-replacement (0.75%) and 28 deaths occurred (7.1%; P = .003) after nonisolated re-replacement, 19 (68%) of which were from coagulopathy, vasoplegia, and multisystem organ failure. In the nonisolated group, incremental risk factors for time-related death after re-replacement included New York Heart Association functional class IV symptoms, concomitant coronary artery bypass grafting, prolonged cardiopulmonary bypass time, and transfusions. CONCLUSIONS: Mitral valve re-replacement for bioprosthetic SVD was associated with low surgical risk and excellent long-term survival. Isolated mitral valve re-replacement for bioprosthetic SVD had near-zero surgical risk. Excessive cardiopulmonary bypass duration and multiple transfusions correlated with increased early mortality in nonisolated procedures, as did preoperative severe heart failure. Optimal surgical plan and timing of surgery are keys to success.

A conservative screening algorithm to determine candidacy for robotic mitral valve surgery.

OBJECTIVE: Patient selection for robotically assisted mitral valve repair remains controversial. We assessed outcomes of a conservative screening algorithm developed to select patients with degenerative mitral valve disease for robotic surgery. METHODS: From January 2014 to January 2019, a screening algorithm that included transthoracic echocardiography and computed tomography scanning was rigorously applied by 3 surgeons to assess candidacy of 1000 consecutive patients with isolated degenerative mitral valve disease (age 58 ± 11 years, 67% male) for robotic surgery. Screening results and hospital outcomes of those selected for robotic versus sternotomy approaches were compared. RESULTS: With application of the screening algorithm, 605 patients were selected for robotic surgery. Common reasons for sternotomy (n = 395) were aortoiliac atherosclerosis (n = 74/292, 25%), femoral artery diameter <7 mm (n = 60/292, 20%), mitral annular calcification (n = 83/390, 21%), aortic regurgitation (n = 100/391, 26%), and reduced left ventricular function (n = 126/391, 32%). Mitral valve repair was accomplished in 996. Compared with sternotomy, patients undergoing robotic surgery had less new-onset atrial fibrillation (n = 144/582, 25% vs n = 125/373, 34%; P = .002), fewer red blood cell transfusions (n = 61/601, 10% vs 69/395, 17%; P < .001), and shorter hospital stay (5.2 ± 2.9 days vs 5.9 ± 2.1 days; P < .001). No hospital deaths occurred, and occurrence of postoperative stroke in the robotic (n = 3/605, 0.50%) and sternotomy (n = 4/395, 1.0%; P = .3) groups was similar. CONCLUSIONS: This conservative screening algorithm qualified 60% of patients with isolated degenerative mitral valve disease for robotic surgery. Outcomes were comparable with those obtained with sternotomy, validating this as an approach to select patients for robotic mitral valve surgery.

Stroke in acute type A aortic dissection: the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD).

OBJECTIVES: Stroke is a serious complication in patients with acute type A aortic dissection (ATAAD). Previous studies investigating stroke in ATAAD patients have been limited by small cohorts and have shown diverging results. We sought to identify risk factors for stroke and to evaluate the effect of stroke on outcomes in surgical ATAAD patients. METHODS: The Nordic Consortium for Acute Type A Aortic Dissection database included patients operated for ATAAD at 8 Scandinavian Hospitals between 2005 and 2014. RESULTS: Stroke occurred in 177 (15.7%) out of 1128 patients. Patients with stroke presented more frequently with cerebral malperfusion (20.6% vs 6.3%, P < 0.001), syncope (30.6% vs 17.6%, P < 0.001), cardiogenic shock (33.1% vs 20.7%, P < 0.001) and pericardial tamponade (25.9% vs 14.7%, P < 0.001) and more often underwent total aortic arch replacement (10.7% vs 4.7%, P = 0.016), compared to patients without stroke. In the 86 patients presenting with cerebral malperfusion, 38.4% developed stroke. Thirty-day and 5-year mortality in patients with and without stroke were 27.1% vs 13.6% and 42.9% vs 25.6%, respectively. Stroke was an independent predictor of early- [odds ratio 2.02, 95% confidence interval (CI) 1.34-3.05; P < 0.001] and midterm mortality (hazard ratio 1.68, 95% CI 1.27-2.23; P < 0.001). CONCLUSIONS: Stroke in ATAAD patients is associated with increased early- and midterm mortality. Preoperative cerebral malperfusion and impaired haemodynamics, as well as total aortic arch replacement, were more frequent among patients who developed stroke. Importantly, a large proportion of patients presenting with cerebral malperfusion did not develop a permanent stroke, indicating that signs of cerebral malperfusion should not be considered a contraindication for surgery.

Repair of iatrogenic pulmonary vein occlusion with a vascularized atrial flap.

Pulmonary vein obstruction is a rare condition, most commonly reported following pulmonary vein catheter ablation for atrial arrhythmia. This novel technique for treatment of pulmonary venous obstruction has the advantage of utilizing an autologous vascularized flap with intact endothelium for reconstruction of the pulmonary vein and to prevent restenosis.

Effects of Sex on Early Outcome following Repair of Acute Type A Aortic Dissection: Results from The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD).

BACKGROUND: Female sex is known to have increased perioperative mortality in cardiac surgery. Studies reporting effects of sex on outcome following surgical repair for acute Type A aortic dissection (ATAAD) have been limited by small cohorts of heterogeneous patient populations and have shown diverging results. This study aimed to compare perioperative characteristics, operative management, and postoperative outcome between sexes in a large and well-defined cohort of patients operated for ATAAD. METHODS: The Nordic Consortium for Acute Type A Aortic Dissection study included patients with surgical repair of ATAAD at eight Nordic centers between January 2005 and December 2014. Independent predictors of 30-day mortality were identified using multivariable logistic regression. RESULTS: Females represented 373 (32%) out of 1,154 patients and were significantly older (65 ± 11 vs. 60 ± 12 years, p < 0.001), had lower body mass index (25.8 ± 5.4 vs. 27.2 ± 4.3 kg/m2, p < 0.001), and had more often a history of hypertension (59% vs. 48%, p = 0.001) and chronic obstructive pulmonary disease (8% vs. 4%, p = 0.033) compared with males. More females presented with DeBakey class II as compared with males with dissection of the ascending aorta alone (33.4% vs. 23.1%, p = 0.003). Hypothermic cardiac arrest time (28 ± 16 vs. 31 ± 19 minutes, p = 0.026) and operation time (345 ± 133 vs. 374 ± 135 minutes, p < 0.001) were shorter among females. There was no difference between the sexes in unadjusted intraoperative death (9.1% vs. 6.7%, p = 0.17) or 30-day mortality (17.7% vs. 17.4%, p = 0.99). In a multivariable analysis including perioperative factors influencing mortality, no difference was found between females and males in 30-day mortality (odds ratio: 0.92, 95% confidence interval: 0.62-1.38, p = 0.69). CONCLUSIONS: This study found no association between sex and early mortality following surgery for ATAAD, despite females being older and having more comorbidities, yet also presenting with a less widespread dissection than males.

Intraoperative assessment of mitral valve repair: Validation of the saline test with nonresectional repair techniques.

BACKGROUND AND AIM: Intraoperative assessment of the repaired mitral valve (MV) by saline testing is a standard maneuver in MV repair. Despite a growing interest in application of nonresectional techniques, the utility of the saline test following repair with neochordae has not been systematically assessed. We sought to determine the accuracy of the saline test following MV repair using nonresectional techniques. MATERIALS AND METHODS: We included 25 adult patients undergoing MV repair for degenerative valve disease between November 2018 and February 2019. The surgical repair was performed using nonresectional techniques with neochordae either through a sternotomy or a robotic approach. RESULTS: Twenty-five patients underwent successful MV repair, all with excellent echocardiographic results. In four patients (16%), the saline test suggested discrete areas of leaflet malcoaptation and leakage, leading to additional repair maneuvers. In 16 patients (64%), the final saline test demonstrated excellent coaptation with little or no leak. In nine patients (36%), the final saline test was inconclusive (ventricle could not be filled) or poor (diffuse leak). Post-repair intraoperative echocardiography demonstrated no or trivial mitral regurgitation in all patients, and no patient required a second pump run. CONCLUSION: After repair with neochordae, a satisfactory saline test indicates a good repair and discrete leaks on the saline test suggest the need for further surgical maneuvers. If the surgeon has employed standard repair techniques using neochordae but the saline test is inconclusive or poor, additional repair maneuvers are generally unnecessary, as intraoperative echocardiography will usually demonstrate a good repair.

Choosing the "Best" surgical techniques for mitral valve repair: Lessons from the literature.

Mitral valve (MV) repair is the procedure of choice to correct mitral regurgitation caused by degenerative MV disease, due to its well-documented superiority over MV replacement. Repair of the MV is feasible in more than 95% of such patients and restores valve function and preserve ventricular function. Surgeons choose from a wide variety of mitral repair techniques, with the ultimate procedure based upon the pathology and the particular surgeon's personal preference. As a result, there is considerable controversy concerning choice of repair techniques and prostheses (ie, annuloplasty device). This targeted review of available data concerning repair of the degenerative valve will inform surgeon decision-making in MV repair.

Repair of bileaflet prolapse in Barlow syndrome: The 4-chord technique.

Barlow syndrome is a form of degenerative mitral valve (MV) disease found in a subset of patients with bileaflet prolapse. The hallmark of Barlow's disease includes excessive and billowing leaflet tissue caused by myxomatous tissue proliferation, elongated chordae, and pronounced annular dilatation. Surgical repair of patients with Barlow's disease is challenging due to the extent of the leaflet and annular abnormalities. Several techniques have been described to repair Barlow's MV including currently popular "non-resectional" approaches. Repair with neochordae has been associated with excellent results and includes the advantage of preserved leaflet mobility and a large surface of coaptation. We describe a simple approach to the use of neochordae to repair bileaflet prolapse in patients with Barlow syndrome and avoid systolic anterior motion.

Superior Canal Dehiscence Surgery Outcomes Following Failed Round Window Surgery.

OBJECTIVE: Round window (RW) occlusion or reinforcement is a less-invasive option compared with direct repair approaches to improve symptoms of superior canal dehiscence (SCD) syndrome. However, RW surgery is associated with variable outcomes. Middle fossa craniotomy or transmastoid repair is an option for SCD patients who fail RW surgery, but it is unknown whether sequential repair following RW plugging improves SCD symptoms or increases complications. The objective of this study is to evaluate outcomes of SCD repair via middle fossa craniotomy following failed RW surgery. STUDY DESIGN: Retrospective review. SETTING: Academic tertiary care center. PATIENTS: Adult patients with SCD syndrome who underwent failed RW surgery followed by sequential middle fossa craniotomy and plugging of the arcuate eminence defect. Patients with SCD associated with the superior petrosal sinus were excluded. INTERVENTION: None. MAIN OUTCOME MEASURE: Prospectively collected pre- and postoperative symptom questionnaires, threshold audiograms, and cervical vestibular evoked myogenic potentials (cVEMP). RESULTS: Seven SCD patients (out of a total of 194 surgical cases at our institution) underwent sequential middle-fossa SCD repair following failed RW surgery. Resolution of symptoms and reversal of diagnostic indicators were observed in the majority of subjects following sequential repair. Two of seven patients underwent a third procedure with plugging of the superior semicircular canal by a transmastoid approach due to the presence of residual symptoms. CONCLUSION: Middle fossa craniotomy and SCD occlusion is a safe and reasonable option for patients who fail RW surgery. Our cohort did not show increased risks of auditory or vestibular dysfunction.

Preoperative dual antiplatelet therapy increases bleeding and transfusions but not mortality in acute aortic dissection type A repair.

OBJECTIVES: Acute aortic dissection type A is a life-threatening condition, warranting immediate surgery. Presentation with sudden chest pain confers a risk of misdiagnosis as acute coronary syndrome resulting in subsequent potent antiplatelet treatment. We investigated the impact of dual antiplatelet therapy (DAPT) on bleeding and mortality using the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database. METHODS: The NORCAAD database is a retrospective multicentre database where 119 of 1141 patients (10.4%) had DAPT with ASA + clopidogrel (n = 108) or ASA + ticagrelor (n = 11) before surgery. The incidence of major bleeding and 30-day mortality was compared between DAPT and non-DAPT patients with logistic regression models before and after propensity score matching. RESULTS: Before matching, 51.3% of DAPT patients had major bleeding when compared to 37.7% of non-DAPT patients (P = 0.0049). DAPT patients received more transfusions of red blood cells [median 8 U (Q1-Q3 4-15) vs 5.5 U (2-11), P < 0.0001] and platelets [4 U (2-8) vs 2 U (1-4), P = 0.0001]. Crude 30-day mortality was 19.3% vs 17.0% (P = 0.60). After matching, major bleeding remained significantly more common in DAPT patients, 51.3% vs 39.3% [odds ratio (OR) 1.63, 95% confidence interval (CI) 1.05-2.51; P = 0.028], but mortality did not significantly differ (OR 0.88, 95% CI 0.51-1.50; P = 0.63). Major bleeding was associated with increased 30-day mortality (adjusted OR 2.44, 95% CI 1.72-3.46; P < 0.0001). CONCLUSIONS: DAPT prior to acute aortic dissection repair was associated with increased bleeding and transfusions but not with mortality. Major bleeding per se was associated with a significantly increased mortality. Correct diagnosis is important to avoid DAPT and thereby reduce bleeding risk, but ongoing DAPT should not delay surgery.

Utility of Postoperative Magnetic Resonance Imaging in Patients Who Fail Superior Canal Dehiscence Surgery.

OBJECTIVE: The etiology of symptoms following primary repair of superior canal dehiscence (SCD) may be due to a persistent third window. However, the extent of surgery cannot be seen on postoperative computed tomography (CT) since most repair materials are not radiopaque. We hypothesize that the extent of superior semicircular canal (SSC) occlusion following primary repair can be quantified based on postoperative magnetic resonance imaging (MRI) data. STUDY DESIGN: Retrospective series. SETTING: Tertiary care center. PATIENTS: Adult patients with a history of SCD syndrome who 1) report persistent symptoms following primary SCD repair and 2) underwent heavily T2-weighted MRI postoperatively. INTERVENTIONS: Analysis of SSC using 3D-reconstruction of CT co-registered with MRI data. MAIN OUTCOME MEASURES: Arc length of fluid void on MRI and quantification of persistent SCD based on CT/MRI co-registration. RESULTS: We identified 9 revision cases from a cohort of 145 SCD repairs at our institution (2002-2017) with CT/MRI data. A fluid void on postoperative MRI (indicating occlusion of the SSC) was observed in all cases (anterior limb: 50.1 degrees [±21.8 SD] and posterior limb 48.1 degrees [±28.5 SD]). Co-registration of CT/MRI revealed a residual defect that was most commonly found along the posterior limb in most patients with persistent symptoms. CONCLUSIONS: The extent of SCD repair can be determined using reformatted or direct T2-weighted MRI sequences in the plane of Pöschl. Co-registration of CT/MRI may be useful to determine the location of a residual superior canal defect and when present was found most commonly along the posterior limb.