Concomitant Cardiac Procedures Research Articles

Postoperative outcome after reoperative isolated tricuspid valve surgery-is there a predictor for survival?

Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery. From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival. At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome. Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.

Concomitant cardiac surgery procedures during left ventricular assist device implantation: single-centre experience.

Additional cardiac pathologies including tricuspid or mitral valve regurgitation are common in left ventricular assist device (LVAD) recipients and whether to address them remains controversial. We present our institutional outcomes of concomitant cardiac procedures, other than temporary right ventricular (RV) support, at the time of LVAD implantation. From 03/2006 to 06/2020, 352 adult patients {median age 60 [interquartile range (IQR): 52-66] years; INTERMACS level 1 29%; INTERMACS level 2 17%; INTERMACS level 3 23%, INTERMACS level 4-6 31%; male 86%} underwent continuous-flow LVAD [Medtronic HVAD® (HVAD) 50%; Abbott HeartMate IITM (HMII) 17%; Abbott HeartMate 3TM (HM3) 33%] implantation. Concomitant valvular procedures were performed in 86 patients (24%) and the majority of patients received the LVAD as bridge to candidacy (BTC) for transplant (74%). Primary study endpoints were short- and mid-term mortality, as well as need for temporary RV support. Tricuspid valve annuloplasty was the most frequent concomitant procedure (77%), followed by aortic valve replacements (AVRs) or Park's stitch (33%). Temporary RV support was common in the study cohort (35%) using either extracorporeal life support (ECLS, 37%) or a temporary RV assist device (RVAD, 63%). A less invasive (LIS) implantation technique was pursued in 12%. Thirty-day mortality was comparable between those with and without concomitant surgery (4% vs. 6%, P=0.426). In-hospital mortality was significantly higher for additional interventions (22% vs. 14%, P=0.05), whereas one-year survival was similar (71% vs. 79%, P=0.106). Concomitant cardiac procedures, especially tricuspid and aortic valve surgery, are frequent but are associated with a higher perioperative morbidity and mortality.

Comparative study between aortic valve replacement through full sternotomy versus mini-sternotomy

Background: The superiority of minimally invasive aortic valve replacement (AVR) over the standard approach is the subject of ongoing research. The aim of this study was to compare the outcomes of AVR through full sternotomy versus mini-sternotomy.
 Methods: We included 60 patients who had AVR; 30 patients underwent AVR through J- or T-shaped mini-sternotomy, and 30 patients had a full sternotomy. We included patients who had isolated AVR and excluded patients who had a concomitant cardiac procedure, redo surgery, or those who needed annular dilatation. All patients had aortic and right atrial cannulation for cardiopulmonary bypass. Study endpoints were operative times, postoperative complications and duration of ICU and hospital stays.
 Results: There were no differences between the two groups preoperatively. Cardiopulmonary bypass time was longer in the mini-sternotomy group (median: 100 (range: 65- 170) vs. 85 (55-160) min, respectively; p= 0.024). Operative time was non-significantly longer in the mini-sternotomy group 5 (4-6) hours vs. 4.5 (4-6) hours in the full sternotomy group (p=0.62). Ventilation time was 10 (4- 50) hours in the mini-sternotomy group vs. 14 (8- 45) hours in the full sternotomy group (p<0.001). ICU stay was shorter in the mini-sternotomy group (2 (1-6.5) vs. 2.5 (1-7) days, respectively, p= 0.014). The total mediastinal drainage was 100 (50 400) ml in the mini-sternotomy group vs. 275 (50- 1000) ml in the full sternotomy group (p= <0.001). There was no difference in wound infection (p= 0.35), tamponade (p˃0.99), and hemothorax (p˃0.99) between both groups.
 Conclusion: Mini-sternotomy AVR had longer cardiopulmonary bypass times; however, there were no differences in the postoperative complications compared to the full sternotomy approach. Mini-sternotomy could be a safe alternative approach to the full median sternotomy for aortic valve replacement.

Pulmonary valve replacement via left anterior minithoracotomy: Lessons learned and early experience.

Median sternotomy has been the standard for pulmonary valve replacement (PVR) in patients with free pulmonary regurgitation (PR) and right ventricular enlargement. With the introduction of transcatheter therapy, the search for an alternate to sternotomy is mandated. We present our early experience with a limited anterior left thoracotomy approach. We used a left anterior mini-thoracotomy in six male patients (15 ± 1.94 years of age) who developed progressive right ventricular enlargement due to chronic PR. Primary diagnoses were tetralogy of Fallot in five patients and pulmonary atresia with an intact septum in another. Four patients had previous median sternotomy with transannular patch repair. The mean right ventricular end-diastolic volume index was 189 ± 27.13 ml/m2 . The procedure was feasible in all patients. All patients had satisfactory adult size pulmonary bioprosthesis (25 or 27 mm valve), with a mean peak gradient of 18 ± 2.40 mmHg across the prosthesis at discharge. All patients were extubated intraoperatively at the end of the procedure and required no intraoperative transfusions. There were no early or late mortalities. Early morbidities included left hemidiaphragm paralysis in one patient, and re-sternotomy for prosthetic valve endocarditis in one. One patient required late reoperation for a common femoral artery pseudoaneurysm. Minimally invasive access for PVR is feasible in both primary and repeat settings, through a limited anterior left minithoracotomy in the absence of intracardiac shunts and the need for other concomitant cardiac procedures. Longer-term studies with a larger number of patients are needed to compare the efficacy of this approach to standard sternotomy.

Multicentre experience with the frozen elephant trunk technique to treat penetrating aortic ulcers involving the aortic arch.

Our goal was to evaluate the use of the frozen elephant trunk (FET) technique for the treatment of penetrating aortic ulcers involving the aortic arch. Between January 2008 and January 2020, a total of 34 patients had the FET technique at 3 aortic centres. The indication for the FET technique was unsuitability for thoracic endovascular aortic repair due to the lack of a sufficient proximal landing zone even after supra-aortic rerouting (subclavian transposition, double transposition), ectasia of the ascending aorta/aortic arch (>40 mm) and/or a shaggy proximal thoracic aorta. Additional cardiac procedures were performed in 14 patients (41%), and the beating heart technique was used in 7 patients (21%). Perioperative mortality was 18% (n = 6); 3 of these patients had a major stroke (9%). No case of spinal cord ischaemia was observed, and 2 patients (6%) developed a non-disabling stroke. After a median follow-up of 7 (first quartile: 1; third quartile 29) months, 2 patients (6%) died (1 of malignant disease and 1 of an unclear cause); 10 additional aortic interventions in all aortic segments (29%; endovascular: n = 8 [24%] and conventional surgical: n = 2 [6%]) were performed in 8 patients. The FET technique is a good treatment option for patients with penetrating aortic ulcers involving the aortic arch unsuitable for thoracic endovascular aortic repair. However, the high obliterative atherosclerotic load in these patients is accompanied by an un-neglectable risk of perioperative neurological injury. Concomitant cardiac surgical procedures are frequently needed. Patients commonly require secondary aortic procedures in all aortic segments, emphasizing the need for thorough primary conceptual planning and stringent follow-up.

Modified Ravitch Procedure for Pectus Excavatum Combined With Complex Cardiac Surgery

Pectus excavatum is common in patients with connective tissue disorders or congenital heart disease undergoing cardiac surgery, and is occasionally severe enough to warrant repair. The optimal surgical strategy is currently debated. We report our experience with simultaneous repair. From January 2012 to January 2020, 11 patients (median age of 35 ± 18 years, range 12-74) underwent a modified Ravitch procedure for severe pectus excavatum performed by a single thoracic surgeon at the time of simultaneous complex cardiac surgery. Eight patients (73%) had a confirmed connective tissue disorder and 2 patients (18%) had recurrent pectus excavatum following a failed Nuss procedure in adolescence. The mean Haller index was 7.3 ± 3.2 (range 3.8-13). The most common concomitant cardiac procedures were valve-preserving aortic root replacement (n=7, 64%) and mitral valve repair (n = 4, 36%). Patients are presented as a case series with descriptive analysis. The median total operative and cardiopulmonary bypass times were 400 minutes (±109 minutes) and 168 minutes (± 43 minutes), respectively. No deaths occurred in-hospital or during follow-up. There were no reoperations for bleeding, tamponade or other indications. No deep or superficial sternal wound infections occurred. Postoperative analgesia regimens were multimodal to facilitate early mobilization and pulmonary hygiene. None of the patients required prolonged ventilation or reintubation for respiratory failure. The mean stay in the intensive care unit was 82 hours (±56 hours) and the mean hospital stay was 9.1 days (2.4 days). Concurrent pectus excavatum repair at the time of cardiac surgery using a modified Ravitch technique can be safely performed by a multi-disciplinary team and should be considered for patients with multiple indications for operation.

Operative risks of the Ross procedure

BackgroundThe risk of the Ross procedure continues to be debated. We sought to determine the immediate outcomes of the Ross procedure in a large consecutive cohort that included patients undergoing reoperative cardiac surgery and/or concomitant cardiac procedures. MethodsBetween March 1987 and September 2019, 702 patients underwent a full root Ross procedure. There were 530 male patients and 172 female patients, with a mean age of 41.6 years. One hundred and one patients had at least one previous sternotomy; 323 patients had concomitant procedures. Patients were stratified into 2 groups: simple and complex. Simple Ross patients were those who had no previous sternotomy and had only minor concomitant procedures performed at the time of their Ross, such as aortoplasty or closure of patent foramen ovale. The complex Ross group included patients with at least one previous sternotomy and/or additional procedures that we deemed complex, such as ascending aortic replacement and mitral valve repair. Complexity and group outcomes were evaluated in consecutive terciles of time. ResultsThere were 7 (1%) operative deaths. Morbidity affected 46 other patients (6.6%). The simple Ross group comprised 419 patients (59.7%), with mortality in 3 (0.7%) and morbidity in 20 (4.8%). The complex Ross comprised 283 patients (40.3%), with mortality in 4 (1.4%) and morbidity in 26 (9.2%). Simple Ross cases decreased in volume over time, with complex cases increasing from 34% to 48%. ConclusionsExcellent results can be achieved with the Ross procedure despite broader indications that include patients with previous sternotomy and with the need for concomitant procedures.

Predictors of Pacemaker Insertion Post-Sutureless (Perceval) Aortic Valve Implantation

The use of rapid deployment sutureless aortic valve replacement (AVR) has become a viable alternative to conventional AVR especially in intermediate and high-risk patients. However, sutureless AVR has been associated with increased rates of permanent pacemaker (PPM) implantation compared with conventionally implanted aortic valve prostheses. The aim of this study was to determine predictive factors for complete heart block requiring insertion of a PPM post-AVR with a Perceval S sutureless valve (LivaNova, London, UK). Such knowledge will help to improve patient counselling, selection and management of patients undergoing sutureless AVR. A retrospective cohort study assessed all patients who underwent insertion of the Perceval sutureless aortic valve prosthesis between July 2015 and September 2019. Medical records were reviewed for demographic, preoperative electrocardiograph (ECG), and operative features related to postoperative PPM implantation and follow-up in the electrophysiology clinic. One hundred and thirty (130) patients without pre-existing PPM underwent sutureless AVR (66.9% male, average age 74.4±6.6 years). Fifty-seven (57) underwent concomitant cardiac surgical procedures. Eight (8) patients underwent redo cardiac surgery. Nineteen (19) of the 130 (14.6%) patients required insertion of a PPM during their postoperative course. Factors associated with PPM insertion were right bundle branch block (overall n=15, PPM vs No PPM: 8/19 vs 7/111 [42.1 % vs. 6.31 %; p<0.01]), longer QRS duration 113.32ms±22.24 ms vs 100.52±20.96 ms (p=0.017) and longer PR Interval 185.166±42.38 ms vs 169.23±25.70 ms (p=0.03). Insertion of rapid deployment sutureless aortic valves in the setting of pre-existing right bundle branch block, prolonged QRS complex and longer PR intervals is associated with increased risk of postoperative PPM requirement. These factors should be considered when preoperatively counselling and postoperatively managing patients when balloon expandable sutureless valves are used.

Anomalous Aortic Origin of a Coronary Artery in Adults

Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden death in youth. However, its significance and optimal management in adults is poorly understood. Our objective is to characterize AAOCA in a large single-center adult cohort based on coronary anatomic variants and surgical management strategies. We reviewed imaging, clinic, and operative reports for 645 adults with an encounter diagnosis code of congenital coronary anomaly from July 2015 to July 2017. After excluding other congenital heart defects, we characterized 167 patients with AAOCAs by anatomic variant, symptoms at diagnosis, indication for advanced imaging, and if performed, surgical repair. To describe the anatomic variant, we classified the origin and course by following the atomization scheme developed by the Congenital Heart Surgeon's Society's AAOCA registry. Among adults with AAOCA, the anomalous origin involved the right coronary artery in 57% (96 of 167), left main coronary artery in 23% (39 of 167), left anterior descending in 2% (4 of 167), circumflex in 16% (26 of 167), and multiple coronaries in 1% (2 of 167). Anomalous right coronary arteries were diagnosed at an older median age than anomalous left main coronary arteries (55 vs 51 years, respectively; P= .026). Surgical repair of AAOCA occurred in 22% (36 of 167) of patients. Concomitant cardiac surgical procedures accompanied 36% (13 of 36) of them. No deaths occurred over a median follow-up of 2.5 years. Most patients in our single-center AAOCA registry were diagnosed in the presence of cardiac symptoms. Concomitant aortic valve disease and coronary atherosclerotic burden complicate both the evaluation and surgical approach to adult AAOCA repair.

Abstract 14563: Improved Outcomes in Patients With Anthracycline-Induced Cardiomyopathy Undergoing Left Ventricular Assist Devices: 10-Year Longitudinal INTERMACS Study

Introduction: Anthracycline-induced cardiomyopathy (AC-CM) presenting as end-stage heart failure may require mechanical circulatory support. Hypothesis: We hypothesize that there is no difference in outcomes after LVAD placement in those with AC-CM compared to other forms of cardiomyopathy. Methods: Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) dataset spanning from 2008 to 2017 was utilized to identify adult AC-CM patients undergoing continuous flow LVAD implantation excluding those who required concomitant cardiac procedures and right ventricular support (RVS). AC-CM patients were compared to those undergoing LVAD placement due to idiopathic dilated cardiomyopathy (IDM) and ischemic cardiomyopathy (ICM). Primary outcome of overall mortality was studied using Cox-proportional hazards model. Secondary outcomes of first infection, ischemic stroke, major bleeding and subsequent RVS were evaluated using Fine-Gray competing risk model accounting for appropriate competing risks. Subgroup analysis based on gender, race, ethnicity, and use of pre-transplant goal directed medical therapy (GDMT) for systolic heart failure was performed. Result: Overall, 248 AC-CM patients underwent continuous flow LVADs in the 10-year period. At 12-months, 85.1% of AC-CM, 86.0% of IDM and 80.2% of ICM patients were alive (log-rank P &lt; 0.001). There was no difference in mortality compared to ICM and IDM ( P &gt; 0.05). However, pre-LVAD GDMT improved mortality in only the AC-CM cohort when compared to those patients who were not on GDMT (adjusted hazards ratio (HR): 0.44; confidence interval (CI): 0.19 - 0.99). AC-CM patients had a higher risk of major bleeding compared to IDM patients (HR: 1.23; CI: 1.01 - 1.50). AC-CM patients had lower risk of stroke compared to ICM patients (HR: 0.31; CI: 0.15 - 0.62). There was no difference in the three subtypes of cardiomyopathy in hazards of first infection or subsequent RVS. Conclusion: Survival rates are similar in AC-CM, ICM and IDM patients who received continuous flow LVAD therapy in the contemporary era. There is improved mortality benefit in AC-CM patients who are on GDMT before LVAD. Further research into bleeding and stroke related disparities is warranted.

Outcomes of tricuspid valve surgery in patients with functional tricuspid regurgitation.

Functional tricuspid regurgitation (fTR) has been amenable to tricuspid valve repair (TVr), with fewer patients needing tricuspid valve replacement (TVR). We sought to review our experience of tricuspid valve surgery for fTR. A retrospective analysis of adult patients (≥18 years) who underwent primary tricuspid valve surgery for fTR (n = 926; mean age 68.6 ± 12.5 years; 67% females) from January 1993 through June 2018 was conducted. There were 767 (83%) patients who underwent TVr (ring annuloplasty, 67%; purse-string annuloplasty, 33%) and 159 (17%) underwent TVR (bioprosthetic valves, 87%; mechanical valves, 13%). The median follow-up was 8.2 years [95% confidence interval (CI) 7.2-8.9 years]. A greater proportion of patients who underwent TVR had severe right ventricular dysfunction (P < 0.001), severe tricuspid regurgitation (P < 0.001) and congestive heart failure (P = 0.001) while the TVr cohort had a greater proportion with severe mitral valve (MV) regurgitation (P < 0.001) and concomitant cardiac procedures. Early mortality (TVR, 9% vs TVr, 3%; P = 0.004), renal failure (TVR, 10% vs TVr, 5%; P = 0.014) and hospital stay (TVR, 15 ± 15 days vs TVr, 12 ± 11 days; P < 0.001) were greater in TVR patients. The TVR cohort had worse survival [hazard ratio (HR) 1.57; 95% CI 1.23-1.99]. Multivariable analysis identified congestive heart failure (HR 1.37; 95% CI 1.10-1.72), renal failure (HR 1.79; 95% CI 1.14-2.82), previous MV surgery (HR 1.35; 95% CI 1.05-1.72) and TVR (HR 1.36; 95% CI 1.03-1.79) as independent risk factors for late mortality. Tricuspid repair for fTR appears to have better early and late outcomes. Since previous MV surgery and TVR are identified as independent risk factors for late mortality, concomitant TVr at the time of index MV surgery may be considered. Early referral before the onset of advanced heart failure may improve outcomes.

Long-term outcomes of sutureless and rapid-deployment aortic valve replacement: a systematic review and meta-analysis.

Sutureless and rapid-deployment aortic valve replacement (SURD-AVR) has become a prominent area of research as the medical community evaluate its place amongst other aortic valve interventions. The main advantages of SURD-AVR established to date are the reduced cross-clamp and cardiopulmonary bypass (CPB) times, as well as facilitating minimally invasive surgery in high-risk surgical patients. This current systematic review and meta-analysis, to our knowledge, is the first focusing on long-term outcomes regarding safety, efficacy and durability of SURD-AVR from available current literature. A literature search via six electronic databases was performed from their inception to November 2019. Inclusion criteria for this systematic review included survival and postoperative echocardiographic outcomes greater than five years in patients who underwent SURD-AVR with either Perceval or Intuity valves. Studies were identified and data extracted by two independent reviewers. Long-term survival outcomes were aggregated using digitized Kaplan-Meier curves where available. After applying predefined inclusion and exclusion criteria, four studies were identified for review. All four studies were observational and in total reported data for 1,998 patients. Almost half (42.4%) of patients underwent SURD-AVR via full sternotomy, with almost one third (30.1%) also undergoing concomitant cardiac procedures. Aggregate overall survival rates at 1-, 2-, 3-, and 5-year follow-up were 94.9%, 91.2%, 89.0%, and 84.2%, respectively. Incidence of strokes (4.8%), severe paravalvular leaks (PVLs) (1.5%) and permanent pacemaker (PPM) insertion (8.2%) at up to 5-year follow-up were acceptable. At 5-year follow-up hemodynamic outcomes were also acceptable for mean pressure gradient (MPG) (range, 8.8-13.6 mmHg), peak pressure gradient (PPG) (range, 18.9-21.1 mmHg) and effective orifice area (EOA) (range, 1.5-1.8 cm2). Evaluation of the evidence reporting long-term outcomes of SURD-AVR suggests that it is a safe procedure for AVR with low rates of complications. Long-term outcomes presented in this review show that not only does SURD-AVR have acceptable survival rates, but also good hemodynamic performance at 5-year follow-up.

Early Outcomes for In Situ Pericardial Roll Repair for Distant Anomalous Pulmonary Venous Return

Repair of anomalous pulmonary venous return (APVR) when veins are remote from the left atrium (LA) is challenging and may eventuate in a higher prevalence of pulmonary vein stenosis, superior vena cava stenosis, or intracardiac baffle obstruction. We describe our experience in 6 patients with a technique, using both anterior and posterior in situ pericardial roll repairs, which reduces these complications. Six patients underwent in situ pericardial roll repair of APVR at Cleveland Clinic between 2018 and 2019. Median age was 40 years (range, 0.25-65 years). Three patients had partial APVR of right upper and middle veins into superior vena cava high above the right pulmonary artery without atrial septal defect; 2 had scimitar syndrome, and the infant had heterotaxy with unbalanced atrioventricular canal and mixed obstructed total APVR. The anomalous pulmonary vein drained into the respective cava far from the LA, which was not ideal for traditional repair techniques. In situ pericardial roll directed anomalous pulmonary vein to the LA. Most patients had concomitant complex cardiac procedures. There was no mortality. Median hospital stay was 23 days (range, 4-60 days) and median follow-up was 20 months (range, 1-36 months). The infant required percutaneous dilatation and stenting of LA anastomosis but since underwent ventricular switch. At last follow-up, pulmonary veins were unobstructed and adult patients were asymptomatic with excellent functional status. In situ autologous pericardial roll is a useful technique that abrogates the need for mobilization of distant anomalous pulmonary vein with direct anastomosis or complex intracardiac baffles. It is suitable for multiple anatomic configurations and can be used in infants and adults.

Concomitant Cardiac Procedures during Implantation of Long-Term Continuous-Flow LVADs: A European Registry for Patients with Mechanical Circulatory Support (EUROMACS) Analysis

There are still discordant data on the effect of concomitant cardiac procedures (CCPs) performed during left ventricular assist device (LVAD) implantation. By investigating on the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) dataset, we identified 2760 patients (pts) who underwent continuous-flow (CF) long-term LVAD implantation. LVAD implantation was associated with a single CCP in 533 pts (19.3%). A propensity score (PS) matching (LVAD pts, n=481 vs. LVAD+CCP pts, n=481) analysis has been perfomed. Intensive care unit (ICU) stay (20.9 vs. 25.5 days, p=0.019) and major bleeding requiring rethoracotomy (4.1% vs. 7.2%, p=0.027) resulted to be more frequent in LVAD+CPP cohort. Hospital mortality (17.4% vs. 22.2%, p=0.063) resulted to be comparable. Only coronary artery bypass grafting (p=0.041, OR 2.03, CI 1.03-4.02) did impact negatively. Extremes of body mass index (BMI), preoperative poor haemodynamics, dependance on inotropes infusion and extracorporeal life support (ECLS) resulted to be risk factors, after adjustment for baseline characteristics. During the mid- to long-term postoperative period, LVAD+CCP population showed higher incidence of bleeding (6.9% vs. 10.8%, p=0.031) and infectious adverse events (9.6% vs. 15.4%, p=0.022), respectively. Follow-up mortality (22.5% vs. 20.3%, p=0.432) resulted to be comparable. Valve surgery concomitant with LVAD implant seemed not to be associated with poor clinical outcomes (p=0.785). Mitral valve repair resulted to be protective in the long-term period (p=0.041), while tricuspid valve repair did not have any influence (p=0.108). No differences were observed by Kaplan-Meier survival analysis in the two cohorts (log-rank p=0.81, PS matched). In summary, performance of CCPs may not increase peri-operative mortality and type of concomitant surgery addressed should be properly weighted. Mid- to long-term survival is not influenced by CCPs. This, however, remains a delicate population to be strictly monitored and homogeneously managed to preserve satisfactory outcomes.

Comparing the Use of Extracorporeal Membrane Oxygenation and Cardiopulmonary Bypass in Lung Transplantation

The method of cardiorespiratory support used during lung transplantation (LTx) has been debated. This study serves to compare survival after LTx in patients who received support from either extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB). We studied 565 LTx performed at a single institution between March 2012 and June 2019. Concomitant cardiac procedures were excluded. 118 underwent CPB, 49 underwent ECMO, and 398 were considered "off-pump", as they received neither support. Comparisons between groups were performed using Chi-squared or ANOVA test. All significant variables from univariate analysis were included in a Cox regression analysis. Survival was assessed by Kaplan-Meier curve and compared by log rank test. P-values <0.05 were considered statistically significant. There was marginal survival difference (p =0.057) between the CPB, ECMO, and "off-pump" groups when analyzed together. When compared to the "off-pump" group in a Cox regression analysis, CPB (RR. 1.52, 95% CI: 0.99-2.31, p=0.054) and ECMO (RR. 1.71, 95% CI: 0.96-3.04, p=0.070) had borderline significant negative impact on survival. When compared amongst the three support groups, analysis of variances and Chi-squared tests showed no differences in recipient sex (p=0.089), race (p=0.42), donor age (p=0.69), donor type (brain death or donation after cardiac death) (p=0.59) and induction (p=0.38). The "off-pump" group was significantly older (p<0.001), had lower lung allocation scores (p=0.001) and had significantly more male donors (p=0.0084). The CPB group had a significantly higher number of double lung transplants (p<0.001). When accounting for these variables individually, Cox regression analysis showed they had no significant impact on survival. This study demonstrates the borderline significance of CPB and ECMO impact on survival and warrants further exploration into the question of proper cardiorespiratory support in LTx.

Safety and Efficacy of Single Dose Del Nido Cardioplegia Solution in Left Ventricular Assist Device Implantation- A Propensity Matched Study

Del Nido cardioplegia (DN) has recently become more in common use as a "single" dose cardioplegia in adult cardiac surgery. However, it is not well described in left ventricular assist device (LVAD) surgery. The purpose of this study was to summarize our clinical experience with single dose DN solution in LVAD implantation and to assess the safety and efficacy of our DN protocol by comparing with conventional cold whole blood cardioplegia (CWB). A total of 524 consecutive patients underwent LVAD implantation between July 2008 and August 2019. Among them, 137 patients who required aortic cross-clamp for concomitant cardiac procedures were included in this study. The DN protocol was to administer the initial dose as a single dose. CWB was given every 20 minutes. Propensity matching identified 40 matched pairs for analysis. Cross-clamp time was significantly shorter in the DN group compared with the CWB group (58± 20 min vs. 70± 33 min, p=0.0497). The retrograde cardioplegia technique was used in 6 (15.0%) patients in the DN group and 36 (90.0%) patients in the CWB group (p<0.0001). There were no significant differences in the rates of postoperative prolonged use of inotropes (>14 days) (DN: 3/40, 7.5% vs. CWB: 3/40, 7.5%, p=1), requiring postoperative right VAD (DN: 2/40, 5.0% vs. CWB: 2/40, 5.0%, p=1), and requiring blood transfusion (Table). Freedom from re-admission at 1 year was similar between two groups (DN: 69.6±7.7% vs. CWB: 74.3±7.5%, Log-Rank p=0.5522). Mid-term clinical outcomes in the patients undergoing LVAD implantation with the DN protocol was acceptable. This study showed the DN protocol was associated with shortened cross-clamp time and less frequent usage of the retrograde cannula technique.

Comparison of biatrial and left atrial maze procedure in concomitant cardiac procedures

Comparison of biatrial and left atrial maze procedure in concomitant cardiac procedures

Multivessel Coronary Artery Disease in Diabetes Mellitus Patients

Coronary artery disease is the most common cardiac disease with a worldwide distribution, and it is responsible for most of the mortalities regarding cardiovascular diseases if not detected early and treated properly. There are many lines in the treatment of coronary artery disease, starting from medical therapy, percutaneous coronary intervention, and coronary artery bypass graft surgery, preference of the choice of the type of the treatment depends on many factors. In fact when coronary artery bypass graft is indicated, although it carries a considerable risk of surgery, but the long-term survival is notably better than the other ways of treatment. This study was done to determine that the prevalence of multivessel coronary artery disease is more in diabetic patients than non-diabetic patients. And more in females than males. In this study hundred, ninety patients were retrospectively studied, all of them underwent coronary artery bypass graft surgery with or without other concomitant cardiac procedures (like valve surgery), but most of them were coronary artery bypass graft alone. We found that the number of coronary arteries affected is strongly related to the presence of diabetes mellitus. And females are more prone to have coronary artery disease than males. Thus diabetes mellitus is the most common risk factor for the development of cardiovascular disease, and the severity of the condition is confirmed by the number of the coronary arteries involved as well as the calcification or multiple stenosis in the same vessel.

Durability of mitral valve repair: A single center experience.

This study aims to present clinical outcomes of mitral valve repair in patients with different etiologies. Between June 2006 and August 2017, a total of 421 consecutive patients (266 males, 155 females; mean age 53.1±15.6 years; range, 5 to 89 years) who underwent mitral valve repair with or without concomitant cardiac procedures were retrospectively analyzed. All pre-, intra-, and postoperative data were collected. Echocardiographic examinations were performed at discharge and during follow-up. Kaplan-Meier analysis was used to estimate overall survival and from residual severe mitral regurgitation, endocarditis and reoperation-free survival rates. The mean follow-up was 58.9±35.1 months. Of the patients, 12 (2.8%) had previous cardiac operations. The most predominant pathology was degenerative disease in 265 patients (62.9%). Repair techniques included ring annuloplasty (n=366, 86.9%), artificial chordae implantation (n=185, 44%), and commissurotomy (n=38, 9%). Overall in-hospital mortality rate was 1.2% (n=5). Echocardiography before discharge showed no/trivial mitral regurgitation in 64.9% (n=270) and mild mitral regurgitation in 34.85% (n=145) of the patients. At the late postoperative period, transthoracic echocardiography revealed moderate mitral regurgitation in 23 patients (5.7%) and severe in 11 patients (2.7%). The mean late survival and freedom from endocarditis, reoperation, and recurrent severe mitral regurgitation rates were 92±0.03%, 98.5±0.07%, 98.1±0.01%, and 94.7±0.02%, respectively. Our study results suggest that mitral valve repair is a safe and effective procedure associated with favorable longterm outcomes in experienced centers.

Aortic Valve Replacement in Bioprosthetic Failure: Insights From The Society of Thoracic Surgeons National Database

This study was conducted to determine the current nationwide trends and outcomes of reoperative surgical aortic valve replacement (SAVR) performed for a degenerated bioprosthesis. Data from The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database were used. All patients who underwent isolated reoperative SAVR for a degenerated aortic bioprosthesis between January 2012 and December 2016 were included. Patients who had other concomitant cardiac surgery procedures or active endocarditis were excluded. Changes during this period were tracked with trend analyses. The number of patients undergoing SAVR for bioprosthetic failure increased substantially between 2012 and 2014 (782 in 2012 to 844 in 2013 and to 900 in 2014; relative change,+7.25%); this trend reversed significantly between 2015 and 2016 (decreased to 873 in 2015 and to 840 in 2016; relative change,-3.4%; P= .005). Patients were older in 2012-2014 (65.80 ± 13.52 years) compared with 2015-2016 (64.45 ± 12.91 years; P= .001). Mean STS-predicted mortality risk score decreased from 4.55% in 2012-2014 to 4.25% in 2015-2016 (P= .001). There was no difference in postoperative stroke (1.80% vs 1.80%, P= .87), renal failure requiring dialysis (2.7% vs 2.8%, P= .69), or operative mortality (3.5% vs 4.0%, P= .36) after reoperative SAVR in 2012-2014 and 2015-2016, respectively. The number of patients undergoing SAVR for a degenerated bioprosthesis is decreasing in the United States, particularly among older and high-risk patients. These trends may reflect the adoption of valve-in-valve transcatheter aortic valve replacement for a degenerated bioprosthesis after its United States Food and Drug Administration approval in2015.