Contemporary outcomes of durable ventricular assist devices in adults with congenital heart disease as a bridge to heart transplantation.

OBJECTIVES: This study aimed to compare the clinical characteristics, risk factors, and overall survival outcomes in adults with congenital heart disease (ACHD) bridged to transplantation with a ventricular assist device (VAD) versus no-VAD. METHODS: The study included 894 ACHD patients aged ≥18 years listed for primary heart transplantation between 2010 and 2019 from the United Network for Organ Sharing database. Primary outcomes were waitlist and 1-year post-transplant mortality between VAD and no-VAD ACHD patients. RESULTS: Of 894 ACHD patients included in the study, 91(10.1%) had VAD support at the time of listing. Patients who needed VAD support were mostly males, heavier, and had higher pulmonary artery pressure than the no-VAD group at the listing. The overall waitlist mortality was 38% in the VAD group than 17% in the no-VAD group (p < 0.01). ECMO use was associated with significantly higher mortality than either group. There was no significant difference in 1-year post-transplant mortality between VAD versus no-VAD at the time of transplant (15% vs. 17%; p = 0.66). Multivariate regression analysis found that BMI <20 kg/m2 (hazard ratio (HR) 1.1; p = 0.01), bilirubin >2 mg/dl (HR 1.1; p = 0.03), creatinine >2 mg/dl (HR 1.3; p = 0.04) and ECMO at transplant (HR 1.4; p = 0.03) increased early post-transplant mortality. CONCLUSIONS: The one-year post-transplant mortality rate was no different for ACHD patients that received VAD versus no-VAD. These findings suggest that a VAD should be considered an option to support ACHD patients as a bridge to heart transplantation.

Interplay between donor and recipient factors impacts outcomes after pediatric heart transplantation: An analysis from the united network for organ sharing database.

BACKGROUND: Donor utilization rates continue to be low for pHT, however, efforts to expand the donor acceptance criteria have shown mixed results in single-institution studies in pediatric and adult transplantation. Purpose of this study is to assess impact of individual and cumulative donor risk factors on transplant outcomes as well as the interplay between donor and recipient risk factors as it relates to transplant outcomes. METHOD: We analyzed pHT UNOS data (2008-2018) to compare the recipient characteristics, donor characteristics, and outcomes based on donor ejection fraction of less than 50% (low EF) and or ischemic time of greater than 4 hours (prolonged IT). RESULTS: A total of 4345 pHT were performed of which 1309 (30.1%) were with prolonged IT and 122 (2.8%) in low EF. Additionally, 58 (1.3%) were performed with both low EF and prolonged IT (combined risk). Rest (2856 patients, 65.7%) was considered low risk. Recipients of combined risk were more likely to be younger, have post-surgical congenital heart disease, be on ECMO or ventilator but less likely on VAD (all P < .01) compared with any other group. Waitlist time was significantly lower for low EF (mean 39 days, 15-109) or combined risk group (36 days, range 15-80) compared with other groups (60 days, range 23-125) (P = .01). 1-year mortality was 8% in low-risk group, 12% in prolonged IT, 14% in reduced EF, and 28% in combined risk patients (P < .01). Number of treated rejections in one year were significantly higher in prolonged IT and combined risk group compared to other groups (P < .01). When stratified by recipient risk, there was no difference in outcomes for low risk, prolonged IT, or low EF groups; however, there were significant survival differences for high-risk recipient versus low-risk recipient in each donor group. CONCLUSION: Lower EF donors performed similar to prolonged IT donor, but were uncommonly used. Acceptance of risk was common in recipients deemed higher risk for waitlist mortality and led to shorter wait times. Caution should be used in accepting combined risk transplants. The recipient risk factors have significant impact on outcomes across all donor risk groups and further analysis will help balance the waitlist mortality with post-transplant outcomes.

Role of implantable cardioverter-defibrillator in patients awaiting heart transplant in the continuous-flow left ventricular assist device era.

Implantable cardioverter-defibrillators (ICDs) have been shown to have survival advantage in advanced heart failure patients. Few studies have evaluated the role of ICDs in patients supported with continuous-flow left ventricular assist devices (CFVADs). We aimed to evaluate the impact of ICD and CFVAD on heart transplant (HTx) waiting list survival. We queried the United Network for Organ Sharing (UNOS) thoracic transplant database between years 2007 and 2016 for patients aged ≥ 18 years listed for HTx. Patients receiving devices other than CFVAD were excluded. Patients were divided into groups-with and without CFVAD and further subdivided into groups-with and without ICD use. Kaplan-Meier curves were used to evaluate the survival outcomes. There were 34 860 patients listed for HTx during study period of which 11 481 (32%) had a CFVAD and 26 139 (75%) had an ICD. Within CFVAD group, patients with ICD were older, more likely male, with higher creatinine and listed as UNOS status 1A. In the No-CFVAD group, 1-year waitlist survival was significantly better with ICD use (81% vs. 73%, P < .0001); however, in CFVAD patients, 1-year survival with ICD use was comparable to No-ICD use (95% vs. 94%, P = .1). Use of ICD is associated with significantly better heart transplant waitlist survival in patients not supported by CFVAD. In patients supported with CFVAD, the ICD does not offer additional survival benefit.

Association of temporal trends in neutrophil lymphocyte ratio on left ventricular assist device patient outcomes.

Neutrophil to lymphocyte ratio (NLR) can predict mortality/complications in left ventricular assist device (LVAD) patients; however, the prognostic value of longitudinal NLR measurements has not been well studied. Here, we examine the mortality/complication incidence in patients with chronically increased NLR verses patients with acutely elevated NLR as a predictor of patient outcomes. This retrospective analysis included 102 patients who underwent LVAD implantation from 2016 to 2018 at a single center. The NLR was calculated at the time of surgery, and at 30 and 90 days after surgery. The NLR values were grouped into categorical data: low, normal (put in range), and high. Patients were classified in 2 groups based on change in their NLR values from surgery to 90 days; the H90 group had sustained increase of NLR over 90-days and the N90 group had normalization of NLR at 90-days. Actuarial survival the between study groups was measured using Kaplan-Meier curves. The N90 group had 50 patients (median age 58 (48-66) years, 21% female) at the time of LVAD placement. Group H90 had 52 patients (median age 64 (52-68) years, 16% female). Median age, body mass index (BMI), bilirubin, creatinine, and BNP at time of implant as well as type of device and implant strategy were comparable between the study groups. The post implant survival for N90 group was significantly better than the H90 group at 1 year (93% vs. 80%) and 2 years (90% vs. 67%) (log-rank P = .001). Early post LVAD survival in patients with elevated NLR over 90 days postoperatively was significantly worse compared to patients who normalized the NLR at 90 days.

Aortic root replacement with Medtronic Freestyle bioprosthesis: 25-year experience.

BACKGROUND: Stentless porcine bioprothesis is a surgical strategy to treat aortic root disease. Use has been limited due to the concern for long-term valve degeneration. This study evaluated the perioperative and late outcomes of patients with aortic root disease requiring root replacement. METHODS: A total of 409 patients underwent aortic root replacement by a single surgeon using a stentless porcine bioroot between February 1996 and May 2020. The cohort was divided into two groups (age ≤65 and >65 years). Descriptive statistics were used to analyze the data and Kaplan-Meier curves used to evaluate long-term outcomes. RESULTS: Patients age >65 years were more likely to be female (p = .01), have hypertension (p = .01), require circulatory arrest (p = .01), and have concomitant coronary artery bypass grafting (CABG) (p = .04). Baseline creatinine >1.8 (p = .20), diabetes (p = .06), and ejection fraction (p = .20) were similar between groups. The 1-, 5-, and 10-year survival for patients age ≤65 years were 92%, 87%, and 69%, respectively, significantly better than patients age >65 (88%, 73%, and 43%, respectively) (p < .01, Figure 1). The 1-, 5-, and 10-year freedom from reoperation for patients ≤65 years were 99%, 97%, and 93% versus 99%, 98%, and 96% in patients age >65 years, respectively (p = .24). CONCLUSION: Patients with aortic root disease can be treated with acceptable perioperative outcomes, long-term survival, and low reoperation rates using a stentless porcine bioprothesis. It should be considered irrespective of age due to its excellent durability and freedom from anti-coagulation requirement.

Combined Heart-Kidney Transplant Versus Sequential Kidney Transplant in Heart Transplant Recipients.

OBJECTIVES: In patients with reduced kidney function there are no established guidelines to suggest combined heart-kidney transplant (HKTx) versus sequential kidney transplant (SKTx) using preoperative value of estimated glomerular filtration (eGFR). METHODS: The United Network for Organ Sharing database was queried from 2000 to 2015 to evaluate survival of HKTx and SKTx population stratified by preoperative eGFR rate <45 mL/min. Aim of the study was to assess the eGFR rate that is most beneficial to perform a concomitant or a SKTx at time of transplant evaluation. RESULTS: In our analysis, patients who required SKTx are recipients that, after heart transplantation, developed or worsened kidney insufficiency due to calcineurin inhibitor nephrotoxicity. In recipients with eGFR <30 or dialysis, a total of 545 received HKTx and 80 received SKTx. The median waiting time between heart and kidney transplant in SKTx group was 6 years. The overall post-transplant survival was 81% and 80% and 75% and 59% at 5 and 1 years for the HKTx and SKTx groups, respectively (P = .04). In recipients with eGFR from 30 to 44, a total of 107 received HKTx and 112 received SKTx. The median waiting time between heart and kidney transplant in SKTx group was 4 years. Overall post-transplant survival showed no statistically significant differences in HKTx group (n=107) compared with SKTx group (n=112) and was 90% and 95% at 1 year and 74% and 52% at 5 years, respectively (P = .4) . CONCLUSIONS: To optimize organ and patient survival, eGFR value can be utilized to discern between HKTx versus SKTx in patients with decreased renal function at the time of heart transplantation. Patients with eGFR<30 or in dialysis presented better survival with HKTx, while both SKTx and HKTx are suitable for patients with eGFR between 30 and 45.

Risk Factors and Outcomes in Redo Coronary Artery Bypass Grafting.

BACKGROUND: Reoperative coronary artery bypass grafting (redo-CABG) has declined during the last decade, while use of percutaneous coronary intervention (PCI) has increased. The aim of this retrospective study was to evaluate risk factors, in-hospital mortality, and long-term survival between first-time CABG and redo-CABG. METHODS: From January 2009 to December 2015, 2,581 patients underwent first-time CABG procedures while 132 underwent isolated redo-CABG. Logistic regression was used to identify risk factors predictive of redo-CABG and after propensity matching the in-hospital morbidity and long-term all-cause mortality were compared. RESULTS: Risk factors for redo-CABG were prior PCI, dyslipidaemia, diabetes and hypertension. After propensity matching there were no significant differences between the redo-CABG (n = 126) and first-time CABG groups (n = 232) in baseline characteristics. The adjusted in-hospital mortality was 3.1% for redo-CABG and 2.1% for first-time CABG (p = 0.55). Redo-CABG required significantly more intraoperative red blood cells (p = 0.03), platelets (p < 0.001), cryoprecipitate (p < 0.007) and fresh frozen plasma (p < 0.001) than first-time CABG. There was no significant difference in reoperation for bleeding (p = 0.72), prolonged ventilation (p = 0.98), postoperative stroke (p = 0.92) or dialysis (p = 0.44). The survival at 1, 3 and 5 years for redo-CABG was 93.5%, 90%, and 85% respectively, and 95.5%, 94.5%, 93% for first-time CABG, respectively (p = 0.2). CONCLUSIONS: Prior PCI after first time CABG and the risk factors for atherosclerotic disease are predictive for redo-CABG. An increased use of blood products is required during redo-CABG. After propensity matching, in-hospital mortality and long-term survival for redo-CABG is comparable to first-time operation. Re-sternotomy does not impact the survival in redo-CABG.

Impact of QRS Duration and Ventricular Pacing on Clinical and Arrhythmic Outcomes in Continuous Flow Left Ventricular Assist Device Recipients: A Multicenter Study.

OBJECTIVES: Wide QRS duration and ventricular pacing are common in recipients of continuous-flow left ventricular assist devices (CF-LVADs) but their impact on outcomes remains unclear. We assessed the clinical and arrhythmic outcomes of CF-LVAD patients with wide QRS or right ventricular (RV) pacing at baseline, compared with those with narrow QRS and those with continued cardiac resynchronization therapy (CRT). METHODS AND RESULTS: A total of 520 patients (57 ± 13 years) with an implantable cardioverter-defibrillator (ICD) (n = 240) or CRT-defibrillator (n = 280) who underwent CF-LVAD implantation at 5 centers in 2007-2015 were studied. Patients were divided into 3 groups: ICD-N (QRS ≤120 ms; n = 134), ICD-W (QRS >120 ms; n = 106), and CRT (n = 280). Mortality, hospitalization, and ventricular arrhythmia (VA) incidence were compared among the groups. Baseline QRS duration was different among the groups (100 ± 13 [ICD-N] vs 155 ± 26 [ICD-W] vs 159 ± 29 ms [CRT]; P < .0001). In the ICD-W group, 37 (35%) had >80% RV pacing at baseline. Median biventricular pacing in the CRT group was 96%. Over 523 days of CF-LVAD support, Kaplan-Meier analysis showed no difference in survival among groups (log rank P = .9). According to multivariate Cox regression, wide QRS duration and RV pacing were not associated with survival. QRS narrowed during CF-LVAD support in the ICD-W and CRT groups but was not associated with improved survival (P = .9). No differences were noted among the groups in hospitalizations (P = .9), VA (P = .2), or ICD shocks (P = .06). CONCLUSIONS: In this large CF-LVAD cohort, a wide QRS duration, high percentage of RV pacing at baseline, and changes in QRS duration after LVAD implantation were not associated with survival. Continued CRT after CF-LVAD implantation also was not associated with improved survival or HF hospitalizations.

Myocardial protection with complementary dose of modified Del Nido cardioplegia during heart transplantation.

Myocardial protection during heart transplantation is achieved by a first dose of heart preservation solution during donor heart harvesting, while there is no consensus about the management of complementary doses during implantation in the recipient. We describe a preliminary case series where modified Del Nido Cardioplegia was used as complementary dose at the time of donor heart implantation.

Changing demographics of heart donors: The impact of donor drug intoxication on posttransplant survival.

Recent reports have shown an increase in the number of organ donors from drug intoxication. The impact of donor drug use on survival after cardiac transplant remains unclear. The aim of our study was to illustrate changes in donor death mechanisms and assess the impact on posttransplant survival. We queried United Network of Organ Sharing thoracic transplant and deceased donor databases to identify patients undergoing heart transplantation between 2005 and 2015. We evaluated annual trends in donor death mechanisms. Recipients were propensity matched (drug-intoxicated-non-drug-intoxicated = 1:2) and posttransplant survival was compared using Kaplan-Meier curves. In total, 19 384 donor hearts were used for transplant during the period (donor age 31.6 ± 11.8 years, 72% male). Use of drug-intoxicated donors increased from 2% (2005) to 13% (2015) and decreased from blunt injury (40%-30%) and intracranial hemorrhage (29%-25%). After propensity matching, posttransplant survival of drug-intoxicated donor hearts was 90%, 82%, and 76% at 1, 3, and 5 years, which was similar to non-drug-intoxicated. Heart transplants using drug-intoxicated donors have significantly increased; however, they have not adversely affected posttransplant survival. Hearts from drug-intoxicated donors should be carefully evaluated and considered for transplant.

Use of drug intoxicated donors for lung transplant: Impact on survival outcomes.

INTRODUCTION: The number of increasing deaths due to the opioid epidemic has led to a potential greater supply of organ donors. There is hesitancy to use drug intoxicated donors, and we evaluated their impact on post-transplant survival. BACKGROUND: Patients ≥18 years of age undergoing lung transplantation and donors from whom at least one organ was donated between January 2005 and March 2015 were selected from the United Network of Organ Sharing database. Baseline characteristics and post-transplant survival were compared between drug intoxicated and all other donors. RESULTS: The utilization of drug intoxicated donors increased from 1.86% in 2005 to 6.23% in 2014. The 2 study groups had similar characteristics including age, gender, and Lung Allocation Score. As compared to all other donors, drug intoxicated donors were younger (29.1 ± 9.4 vs 34.6 ± 13.4 years, P < .0001), less likely to be male (52% vs 61%, P < .0001), and had a greater smoking history (14% vs 11%, P .04). There was no difference in post-lung transplant survival at 1, 3, and 5 years between drug intoxicated donors (85%, 64%, and 47%) and non-drug intoxicated donors (83%, 65%, and 51%). CONCLUSION: Transplantation utilizing drug intoxicated donor lungs has significantly increased over the past decade without significantly impacting post-transplant survival.

Comparison of total artificial heart and biventricular assist device support as bridge-to-transplantation.

BACKGROUND: The use of left ventricular assist devices (LVAD) has increased significantly in the last decade. However, right heart dysfunction remains a problem despite the improved outcomes with continuous-flow LVADs. Surgical options for bridge to transplantation (BTT) in patients with biventricular failure are total artificial heart (TAH) or biventricular support (BiVAD). This study examines the differences in pre- and post-transplantation outcomes and survival in patients with TAH or BiVAD support as BTT. METHODS: The United Network of Organ Sharing database was retrospectively queried from January 2005 to December 2014 to identify adult patients undergoing heart transplantation (n = 17,022). Patients supported with either TAH (n = 212) or BiVAD (n = 366) at the time of transplantation were evaluated. Pre- and post-transplantation Kaplan-Meier survival curves were examined. Cox regression model was used to study the hazard ratios of the association between TAH versus BiVAD support and post-transplant survival. RESULTS: The median age of the study groups was 49.8 ± 12.9 (TAH) and 47.2 ± 13.9 (BiVAD) years (range 18-74 years). There were more men, 87% versus 74%, in the TAH group (p < 0.0001) with greater body mass index, 27.3 ± 5.2 versus 25.6 ± 4.7 (p < 0.0001), compared to those with BiVADs. Creatinine was higher, 1.7 + 1.2 versus 1.3 + 0.8 mg/dL (p < 0.0001), in the TAH group before transplant. The 30-day, one-, and three-year post-transplantation survival was 88%, 78%, and 67%, respectively, for patients with TAH support versus 93%, 83%, and 73% (p = 0.06) for patients with BiVAD support. Cox regression model shows pre-transplant creatinine (HR = 1.21, p = 0.008) is associated with a lower post-transplant survival. TAH is not associated with a worse post-transplant survival (p = 0.1). There was no difference in wait-list survival in patients supported with TAH or BiVAD (p = 0.8). CONCLUSION: Although there has been a recent increase in the use of the TAH as BTT, BiVAD support remains a viable option with similar post-transplant survival.

Impact of cardiac resynchronization therapy on clinical outcomes in patients with continuous-flow left ventricular assist devices.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) can improve survival in left ventricular assist device (LVAD) recipients. However, the impact of cardiac resynchronization therapy (CRT-D) on outcomes in continuous-flow left ventricular assist device (CF-LVAD) patients is not known. We sought to determine if CRT-D improved clinical outcomes in CF-LVAD patients compared with ICDs alone. METHODS AND RESULTS: Sixty-one consecutive CF-LVAD patients with an ICD or CRT-D were evaluated. Impacts of CRT-D on mortality, all-cause hospitalization, and incidence of atrial (AA) and ventricular (VA) arrhythmias after LVAD implantation was compared with patients with ICD alone. Of the 61 LVAD patients, 31 (age 59.8 ± 16 years, 84% male) had CRT-D and 30 (age 57.2 ± 13 years, 74% male) had ICD. Before LVAD implantation, no significant differences were noted between the groups in demographic and clinical characteristics, LVAD indications, and incidence of AA and VA. Over 682 ± 45 days of LVAD support, 8 patients (25.8%) died in the CRT-D arm versus 5 (16.7%) in the ICD arm (P = .35). No differences were noted between the CRT-D and ICD groups in all-cause (96.8 vs 93.3%; P = .63) and HF (19.4 vs 26.7%; P = .78) hospitalizations, left ventricular (LV) end-diastolic diameter (6.4 ± 1.5 vs 6.2 ± 1.1 cm, P = .47), and incidence of AA (35.4% vs 33.3%; P = .80), VA (29% vs 26.6%; P = .86), and ICD shocks (22.6% vs 16.7%; P = .93). Beta-blocker and antiarrhythmic drug use after LVAD implantation was similar in both groups. CONCLUSIONS: In patients with refractory HF who received CF-LVADs, CRT-D, compared with ICD, did not significantly improve mortality, all-cause hospitalization, LV dimensions, and incidence of AA and VA.

Perioperative Morbidity and Outcomes in Pediatric Patients Transitioned From Extracorporeal Membrane Oxygenation to Ventricular Assist Device Support: A Study of the Society of Thoracic Surgeons Congenital Heart Surgery Database.

As a bridge to transplant strategy, children transitioned from extracorporeal membrane oxygenation (ECMO) to ventricular assist device (VAD) have higher waitlist mortality compared with those who receive de novo VAD. However, the contribution of the immediate perioperative period and differences in the two groups are not well studied. We performed a nested case-control study between children receiving de novo VAD (group 1) and those transitioned from ECMO to VAD (group 2) between 2014 and 2019 using The Society of Thoracic Surgeons (STS) database. A total of 735 children underwent VAD placement with 498 in group 1 and 237 in group 2. Patients in group 2 were significantly younger, smaller, and significantly sicker, were twice as likely to transition to biventricular VAD and need unplanned reoperations. Overall mortality was 16% for group 1 and 34% for group 2 ( p < 0.01). Regression analysis showed that ECMO use (odds ratio [OR], 2.17 [1.3-3.4]), ventilator need (OR, 2.2 [1.3-3.9]), and cardiogenic shock (OR, 1.8 [1.2-2.8]) were all independent preoperative predictors of VAD mortality while dialysis need (OR, 25.5 [8.6-75.3]), stroke (OR, 6.2 [3.1-12.6]), and bleeding (OR, 1.9 [1.1-3.4]) were independent postoperative predictors of VAD mortality within 30 days (all p < 0.05). The study demonstrated significant baseline differences between the two cohorts, warranting avoidance of comparison. Early elective VAD placement in this cohort of patients should be sought to avoid interim ECMO and high post-VAD mortality.

Ambulatory Extracorporeal Membrane Oxygenation Use in Patients Listed for Lung Transplant.

There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) to bridge critically ill patients to lung transplant (LTX). This study evaluates how ambulatory status on ECMO affected waitlist and post-LTX outcomes. The United Network of Organ Sharing (UNOS) database was queried for patients aged of greater than or equal to 18 years and between 2016 and 2021 to identify pre-LTX patients supported by ECMO. The patients were classified in venous-arterial (VA) ECMO and veno-venous (VV) ECMO cohorts and further classified as ambulatory (AMB) and non-AMB (nAMB). Each cohort was controlled against the non-ECMO patients. Univariate statistical tests, as well as Kaplan-Meier survival curves, were used for analysis. The 90 day waitlist survival was the highest among the non-ECMO group (96%), but both AMB VV and VA groups had superior survival compared to the nAMB group (85% vs. 75%, 78% vs. 65%, p < 0.01). After adjusting for the median lung allocation score (LAS) (88) in the VV ECMO group, the waitlist survival was superior in the AMB VV ECMO compared to those not on ECMO (86% vs. 78%, p > 0.01). The 1 year post-LTX survival between non-ECMO and AMB VV ECMO was comparable (88% vs. 88%, p = 0.66). Ambulating patients or use of physical therapy while on ECMO can help improve lung transplant outcomes.

Cannula Placement for Cerebral Protection Without Circulatory Arrest in Patients Undergoing Hemiarch Aortic Aneurysm Repair.

BACKGROUND: Aortic aneurysms involving the proximal aortic arch, which require hemiarch-type repair, typically require circulatory arrest with antegrade cerebral perfusion. Left carotid antegrade cerebral perfusion (LCP) via distal arch cannulation without circulatory arrest was used in this study's patient population. The goal was to assess the operative efficiency and clinical outcomes of using a distal arch cannulation technique that would not require any hypothermic circulatory arrest (HCA) time compared with more traditional brachiocephalic artery cannulation with right-sided unilateral antegrade cerebral perfusion (RCP) and HCA. METHODS: A single-center retrospective review of patients with replacement of the distal ascending aorta involving the proximal arch was performed. Patients with an intramural hematoma or dissection were excluded. Between January 2015 and December 2019, 68 adult patients had undergone a hemiarch repair because of aneurysmal disease. Analysis of baseline demographics, operative data, and clinical outcomes was performed. RESULTS: Comparing the 68 patients: 21 patients were treated with RCP (via brachiocephalic artery graft with HCA), and 47 patients were treated with LCP (via distal aortic arch cannulation with cross-clamp between the brachiocephalic and left common carotid arteries without HCA). Baseline characteristics and outcomes were evaluated for both groups. The LCP group was younger (LCP median [IQR] age, 60 [53-65] years vs RCP median [IQR] age, 67 [59-71] years]. Sex, race, body mass index, comorbidities, and ejection fraction were similar between the groups. Cardiopulmonary bypass time (LCP, 123 minutes vs RCP, 149 minutes) and unilateral cerebral perfusion time (LCP, 17 minutes vs RCP, 22 minutes) were longer in the RCP group. Bleeding, prolonged ventilatory support, kidney failure, and length of stay were similar. In-hospital mortality was 2% in the LCP group vs 0% in the RCP group. Stroke occurred in 2 patients (4.2%) in the LCP group and in 0% of the RCP group. Mortality at 6 months in the LCP and RCP groups was 3% and 10%, respectively. CONCLUSION: Distal arch cannulation with LCP without HCA is a reasonable and safe alternative strategy for patients requiring hemiarch replacement for aneurysmal disease. This technique may provide additional benefits by avoiding circulatory arrest in these complex cases.

Early and midterm outcomes following surgery for acute type A aortic dissection.

OBJECTIVE: Surgical repair of acute Type A aortic dissection (AADA) is still associated with high in-hospital mortality. We evaluated the impact of perioperative risk factors on early and midterm survival. METHODS: Retrospective (2002-2011) database analysis at a single institution of 132 consecutive AADA patients (88 male, age 59.8 ± 13.6). All but five patients underwent repair with open distal anastomoses and hypothermic circulatory arrest: aortic valve replacement/root replacement (n=44, 33.3%) and valve re-suspension/repair (n=88, 66.7%). Ascending aorta, hemi-arch, and total arch repairs were performed in 11, 113, and eight patients, respectively. Antegrade and retrograde cerebral perfusion were used in all but six patients. RESULTS: Overall in-hospital mortality was 17.4% (n=23). Actuarial survival at one, five, and eight years was 82%, 72%, and 62%, respectively. Perfusion time (cardiopulmonary bypass) (226.5 ± 71.3 vs. 177.5 ± 51.7, p=0.0002), aortic cross-clamp time (min) (132.8 ± 45.7 vs. 109.8 ± 41.2, p=0.01), aortic arch (T2) tear (31% vs. 14%, p=0.03), instability (26% vs. 11%, p=0.02), postoperative stroke (38% vs. 14%, p=0.009), and low cardiac output (50% vs. 15%, p=0.04) all correlated with increased perioperative mortality. A Cox proportional hazard model showed perfusion time (hazard ratio [HR]=1.01), postoperative stroke (HR=2.73), age (HR=1.03), and unstability (HR=1.8) as significant risk factors (p<0.05) affecting the overall survival. CONCLUSION: There is a modern trend towards improving overall perioperative outcomes after surgical repair of AADA; however, early mortality and morbidity remain high even in aortic surgery referral centers.

Minimally Invasive Esophagectomy Is Associated with Superior Survival Compared to Open Surgery.

INTRODUCTION: Minimally invasive esophagectomy (MIE) has not been associated with a long-term survival advantage compared to open esophagectomy (OE). We investigated survival differences between MIE, including laparoscopic and robotic, and OE. METHODS: Patients undergoing esophagectomy from 2010 to 2014 with T1-4N0-3M0, adenocarcinoma or squamous cell histology, in middle or lower esophagus were queried from the National Cancer Database and stratified into groups based on their surgical procedure: robotic, laparoscopic, or OE. Propensity matching (1:1) was done between robotic and laparoscopic to produce an MIE group. The MIE group was matched to OE yielding a 1:1:2 matching of robotic:laparoscopic:OE. Postoperative outcomes and survival (Kaplan-Meier) were compared between groups. RESULTS: Prior to matching, 7,163 patients met inclusion criteria and a greater portion underwent OE (67.7%) than MIE (laparoscopic 24.9% and robotic 7.4%). Matching yielded similar groups (robotic = 527, laparoscopic = 527, and OE =1054). Compared to OE, MIE patients had a significantly greater number of nodes sampled and trended toward increased R0 resections (96.1% vs 94.3%, P = .053). OE was associated with a longer median postoperative stay (10 vs 9 days, P = .001). Mortality at 30 and 90 days was similar. However, postoperative survival for MIE was significantly greater than OE (P < .001). No survival difference existed between robotic and laparoscopic (P = .723). CONCLUSIONS: MIE is associated with increased number of nodes examined and a shorter postoperative length of stay. After propensity matching, patients undergoing MIE had better long but not short-term survival than OE. This benefit seems to be independent of the use of robotic technology.

Inflammatory aneurysms of the ascending aorta: diagnosis and surgical treatment.

Inflammatory aortic aneurysms (IAAs) are rare and located mainly in the infra-renal abdominal aorta. The ascending aorta has been typically spared from this process. We report on two cases of ascending aortic inflammatory aneurysms and describe the available literature on this rare entity.