Aortic root allograft reoperations.

OBJECTIVE: To investigate outcomes after aortic root allograft reoperation, identify risk factors for morbidity and mortality, and describe practice evolution since publication of our 2006 allograft reoperation study. METHODS: From January 1987 to July 2020, 602 patients underwent 632 allograft-related reoperations at Cleveland Clinic: 144 before 2006 (early era, which suggested radical explant was superior to aortic-valve-replacement-within-allograft [AVR-only]), and 488 from 2006 to present (recent era). Indications for reoperation were structural valve deterioration in 502 (79%), infective endocarditis in 90 (14%), and nonstructural valve deterioration/noninfective endocarditis in 40 (6.3%). Reoperative techniques included radical allograft explant in 372 (59%), AVR-only in 248 (39%), and allograft preservation in 12 (1.9%). Perioperative events and survival were assessed among indications, techniques, and eras. RESULTS: Operative mortality by indication was 2.2% (n = 11) for structural valve deterioration, 7.8% (n = 7) in those with infective endocarditis, and 7.5% (n = 3) for nonstructural valve deterioration/noninfective endocarditis, and by surgical approach 2.4% (n = 9) after radical explant, 4.0% (n = 10) for AVR-only, and 17% (n = 2) for allograft preservation. Operative adverse events occurred in 4.9% (n = 18) of radical explants and 2.8% (n = 7) of AVR-only procedures (P = .2). Patients undergoing radical explants received larger valves than those undergoing AVR-only (median, 25 vs 23 mm). CONCLUSIONS: Aortic root allograft reoperations present a technical challenge but can be performed with low mortality and morbidity. Radical explant offers outcomes similar to AVR-only while allowing for implant of larger prostheses. Increasing experience with allograft reoperations has permitted excellent outcomes; thus, risk of reoperation should not dissuade surgeons from using allografts for invasive aortic valve infective endocarditis and other indications.

Surgical ablation of atrial fibrillation in hypertrophic obstructive cardiomyopathy: Outcomes of a tailored surgical approach.

OBJECTIVE: To assess outcomes of concomitant ablation for atrial fibrillation (AF) in patients with preoperative AF undergoing septal myectomy for hypertrophic obstructive cardiomyopathy. METHODS: From 2005 to 2016, 67 patients underwent concomitant ablation for AF and septal myectomy and had a follow-up beyond a 3-month blanking period. Ablation strategy (pulmonary vein isolation [PVI], modified Cox-maze III [CM-III], or Cox-maze IV [CM-IV]) was tailored to preoperative AF burden, with high AF burden defined as persistent AF or need for cardioversion. AF recurrence was analyzed as a time-related event and predictors of recurrence identified using a random forest methodology. RESULTS: A total of 38 patients (57%) had low AF burden and 29 (43%) high burden. Patients with low AF burden most frequently underwent PVI (68%). Patients with high AF burden more frequently underwent CM-III (62%) or CM-IV (35%). Besides the preoperative AF burden, baseline characteristics were similar between patients receiving CM-III, CM-IV, and PVI. After surgery, the maximum provoked left ventricular outflow tract (LVOT) gradient decreased from 99 ± 34 to 18 ± 11mm Hg (P < .001). Eight patients (12%) required a permanent pacemaker. Cumulative AF recurrence at 1, 2, and 5 years was 11%, 22%, and 48%, respectively. Age, low preoperative resting LVOT gradient, and large left atrial diameter were predictors of AF recurrence. CONCLUSIONS: Surgical outcomes of concomitant ablation for AF and septal myectomy are good, although recurrence of AF by 5 years is frequent.

Acute Type A Dissection Repair by High-Volume Vs Low-Volume Surgeons at a High-Volume Aortic Center.

BACKGROUND: Previous studies suggest improved outcomes for acute type A dissections (ATAAD) treated at high-volume centers. It is unclear if outcomes are a result of individual surgeon experience or inherent resources available at high-volume centers. To explore this question, we stratified outcomes for ATAAD repair by low-volume and high-volume surgeons at a high-volume center. METHODS: We reviewed our institutional experience with ATAAD between 1999 and 2016 (n = 580). To evaluate surgeon experience with ATAAD repair, we categorized surgeons as high-volume aortic surgeons (HVASs) (> 10 cases/year) or low-volume aortic surgeons (LVASs) (≤ 10 cases/year). Analysis was stratified according to the following: HVAS in primary and first assist roles, HVAS as primary with LVAS as first assist, LVAS as primary and HVAS as first assist, and LVAS in both roles. RESULTS: The total experience for HVAS and LVAS as primary surgeon for the study period was 513 and 67, respectively. Mean annual experience as primary surgeon was 15.2 cases for HVAS and 3.4 cases for LVAS. In-hospital mortality was 14.0% if an HVAS was present and 24.0% with an all-LVAS team (P = .27). After adjusting for preoperative factors, the mortality odds ratio (OR) for an all-LVAS team was 3.72 (P = .01). CONCLUSIONS: ATAAD repair by an all-LVAS team had nearly a 4-fold increase in-hospital mortality compared with an all-HVAS team. Improved outcomes at high-volume centers may be predominantly due to surgeon experience and not from center-specific resources. This study may have implications on call coverage for ATAAD repair at high-volume centers.

Phase of Care Mortality Analysis According to Individual Patient Risk Profile.

BACKGROUND: Phase of care mortality analysis (POCMA) is a quality improvement tool categorizing triggers for mortality into phases of patient care. However, the relationship between a patient's risk profile and the triggers for mortality is incompletely understood. METHODS: POCMA was implemented for cases with available Society of Thoracic Surgeons (STS) risk models. Risk-adjusted rates were obtained from the STS database. Mortality triggers were categorized by the phase of occurrence (preoperative, intraoperative, intensive care unit [ICU], postoperative floor, and discharge). Patients were then stratified by STS risk score: low risk (<4%), intermediate (4% to 8%), and high risk (>8%). RESULTS: A total of 3,919 isolated coronary artery bypass grafting (CABG), 901 isolated valve, and 321 CABG plus single-valve procedures were performed from 2012 to 2018, with 4.6% crude mortality and a median STS risk score of 5.8%. POCMA was performed on 67 patient mortalities, with triggers occurring in the following phases of care: 49.3% preoperative, 13.4% intraoperative, 23.9% ICU, 3.0% postoperative floor, and 10.4% discharge phase. Mortality distribution was bimodal, occurring mostly in low-risk (37.3%) and high-risk (38.8%) patients. For low-risk patients, the trigger for mortality most frequently occurred during the postoperative ICU phase, while for high-risk patients, the trigger for mortality most frequently occurred during the preoperative phase. CONCLUSIONS: Mortality had a bimodal distribution with respect to patient risk profile. Phase-of-care triggers for mortality differed according to patient risk profile: low-risk triggers during the postoperative ICU phase versus high-risk triggers typically during the preoperative phase. Specific focus on phases according to the patient's risk profile represents an opportunity to improve quality and outcomes.

Minimally Invasive Mitral Valve Repair for Acute Papillary Muscle Rupture During Pregnancy.

Acute papillary muscle rupture during pregnancy is a rare cardiac condition with potential for 200% mortality. We describe a 28-year-old morbidly obese woman at 27 weeks gestation who presented with acute decompensated mitral regurgitation secondary to spontaneous papillary muscle rupture. After hemodynamic stabilization and caesarean delivery, we performed an emergent mitral valve repair through a minimally invasive right thoracotomy.