Concomitant Cardiac Procedures Research Articles

Outcomes of Concomitant Cardiac Surgical Procedures Performed During Pediatric Lung Transplantation in the United States.

Data on concomitant cardiac surgery (CCS) performed during pediatric lung transplantation (LTx) is limited. Therefore, we conducted a multi-institutional analysis to identify the incidence and outcomes of CCS in pediatric (< 18 years) LTx recipients by merging data (2004-2023) from the United Network for Organ Sharing (UNOS) and Pediatric Health Information System (PHIS) databases. Of the total of 596 pediatric LTx recipients, 87 (15%) underwent CCS. The majority of these cardiac surgeries were atrial septal defect (ASD) closure (90%) followed by aortic arch/descending aortic repair (3%), atrial repair (3%), ventricular septal defect closure (2%), patent ductus arteriosus ligation (2%), and tricuspid valve repair (2%). The median age at LTx was 3years (IQR: 0-12). Pulmonary hypertension (PHT) was the predominant indication for LTx (54%). Survival to discharge was 94% and 5-years survival was 64%. Our findings indicate CCS in children undergoing LTx has acceptable outcomes.

Surgical options for atrial fibrillation treatment during concomitant cardiac procedures.

Current guidelines recommend concomitant surgical ablation (SA) of atrial fibrillation (AF) in the context of mitral valve disease. A variety of energy sources have been tested for SA to perform effective transmural lesions reliably. To date, only radiofrequency and cryothermy energies are considered viable options. The gold standard for SA is the Cox-Maze ablation set, especially for non-paroxysmal AF (nPAF), with the aim of interrupting macro-reentrant drivers perpetuating AF, without hampering the sinus node activation of both atria, and to maintain the atrioventricular synchrony. Although the efficacy of SA in terms of early and late sinus rhythm restoration has been clearly demonstrated over the years, concomitant AF ablation is still underperformed in patients with AF undergoing cardiac surgery. From a surgical standpoint, concerns have been raised about whether a single (left) or double atriotomy would be justified in AF patients undergoing a "non-atriotomy" surgical procedure, such as aortic valve or revascularization surgery. Thus, an array of simplified lesion sets have been described in the last decade, which have unavoidably hampered procedural efficacy, somewhat jeopardizing the standardization process of ablation surgery. As a matter of fact, the term "Maze" has improperly become a generic term for SA. Surgical interventions that do not align with the principles of forming conduction-blocking lesions according to the Maze pattern, cannot be classified as Maze procedures. In this complex scenario, a tailored approach according to the different AF patterns has been proposed: for patients with concomitant nPAF, a biatrial Cox-Maze ablation is recommended. Conversely, it might be reasonable to limit lesions to the left atrium or the pulmonary veins in patients with paroxysmal AF (PAF) in some clinical scenarios. The aim of this review is to provide an overview of the current ablation strategies for patients with AF undergoing concomitant cardiac surgery.

Impact of transcatheter heart valve type on outcomes of surgical explantation after failed transcatheter aortic valve replacement: the EXPLANT-TAVR international registry.

There are limited data on the impact of transcatheter heart valve (THV) type on the outcomes of surgical explantation after THV failure. We sought to determine the outcomes of transcatheter aortic valve replacement (TAVR) explantation for failed balloon-expandable valves (BEV) versus self-expanding valves (SEV). From November 2009 to February 2022, 401 patients across 42 centres in the EXPLANT-TAVR registry underwent TAVR explantation during a separate admission from the initial TAVR. Mechanically expandable valves (N=10, 2.5%) were excluded. The outcomes of TAVR explantation were compared for 202 (51.7%) failed BEV and 189 (48.3%) failed SEV. Among 391 patients analysed (mean age: 73.0±9.8 years; 33.8% female), the median time from index TAVR to TAVR explantation was 13.3 months (interquartile range 5.1-34.8), with no differences between groups. Indications for TAVR explantation included endocarditis (36.0% failed SEV vs 55.4% failed BEV; p<0.001), paravalvular leak (21.2% vs 11.9%; p=0.014), structural valve deterioration (30.2% vs 21.8%; p=0.065) and prosthesis-patient mismatch (8.5% vs 10.4%; p=0.61). The SEV group trended fewer urgent/emergency surgeries (52.0% vs 62.3%; p=0.057) and more root replacement (15.3% vs 7.4%; p=0.016). Concomitant cardiac procedures were performed in 57.8% of patients, including coronary artery bypass graft (24.8%), and mitral (38.9%) and tricuspid (14.6%) valve surgery, with no differences between groups. In-hospital, 30-day, and 1-year mortality and stroke rates were similar between groups (allp>0.05), with no differences in cumulative mortality at 3 years (log-rank p=0.95). On multivariable analysis, concomitant mitral surgery was an independent predictor of 1-year mortality after BEV explant (hazard ratio [HR] 2.00, 95% confidence interval [CI]: 1.07-3.72) and SEV explant (HR 2.00, 95% CI: 1.08-3.69). In the EXPLANT-TAVR global registry, BEV and SEV groups had different indications for surgical explantation, with more root replacements in SEV failure, but no differences in midterm mortality and morbidities. Further refinement of TAVR explantation techniques are important to improving outcomes.

Comparison of Beating-Heart Technique Versus Aortic Cross-Clamping in Tricuspid Valve Surgery.

Tricuspid valve surgery can be performed on a beating heart or on an arrested heart. We aimed to compare the outcomes of tricuspid valve surgery using these two different approaches. Between January 2015 and February 2020, 204 patients who underwent tricuspid valve surgery along with concomitant cardiac surgical procedures were included in the study. Techniques of cross-clamping and beating-heart tricuspid surgery were applied to 103 and 101 patients, respectively. Concomitant valvular and/or coronary interventions were performed under cross clamping in both groups. Results from the preoperative period, immediate postoperative period, and six-month postoperative interval were compared between the groups. There were no differences in demographic characteristics or preoperative grades of tricuspid valve regurgitation between the groups. Duration of mechanical ventilation, and stays in the intensive care unit and hospital were significantly shorter in patients operated on using the beating-heart technique. Additionally, re-exploration surgery and mortality rates were significantly lower in the beating-heart group. Postoperative six-month echocardiography findings related to tricuspid valve regurgitation, maximum and minimum gradients of the tricuspid valve, and pulmonary arterial pressure were also lower in the beating-heart group. Beating-heart tricuspid valve surgery may be preferable to the cross-clamping technique to avoid clamp-induced ischemia, which can lead to worsened postoperative outcomes.

Transcatheter pulmonary valve implantation in clinical practice: A nationwide survey of cardiological implanting and non-implanting physicians

AimTranscatheter Pulmonary Valve Implantation (TPVI), when feasible, is the first-line approach to pulmonary valve replacement. Our aim was to obtain a picture of current TPVI practice in Italy. MethodsAfter conducting a literature review on TPVI, online surveys were devised by an Advisory Board of 10 experts from the three Italian reference centers for congenital heart diseases and sent electronically to physicians working either in implanting center or in referral non-implanting cardiologic centers. ResultsApproximately 450 physicians across Italy were invited to contribute. 82 (18%) physicians answered. EchoColorDoppler, electrocardiogram and cardiac magnetic resonance were considered the first line approach to monitor these patients, before and after TPVI.For non-implanting centers, reasons for non-referral of patients for PVR were: paucisymptomatic disease (67%) and patients’ poor adherence to disease management programs (41%), but also the lack of connections with specialized centers (33%). For implanters, the main reasons for refraining from TPVI were: high risk for coronary compression (67% first rank), the need for concomitant cardiac surgical procedures (39% first rank) and the unsuitable anatomy of the conduit (39% first rank). The availability of new larger valves of a self-expandable nature was indicated as a key technological development for expanding the cohort of patients currently eligible for TPVI. ConclusionsDespite a non-invasive imaging protocol for the follow up and selection of patients candidate to TPVI is well implemented in Italy, there is still a lack in connections between non-implanting and implanting centers.

Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study.

All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.

Long-term outcomes of surgical aortic valve replacement in patients receiving chronic dialysis.

Surgical aortic valve replacement (SAVR) has been the standard treatment for symptomatic severe aortic stenosis, which is common among patients receiving long-term dialysis. The aim of this study was to report the long-term outcomes of SAVR in patients receiving chronic dialysis and to identify independent risk factors for early and late mortality. Every consecutive patient with SAVR with or without concomitant cardiac procedures in British Columbia between January 2000 and December 2015 was identified from the provincial cardiac registry. The Kaplan-Meier method was used to estimate survival. Univariate and multivariable models were conducted to determine independent risk factors for short-term mortality and reduced long-term survival. Between 2000 and 2015, 654 patients receiving dialysis underwent SAVR with or without concomitant procedures. The mean follow-up was 2.3 (standard deviation 2.4) years (median 2.5 yr). The overall 30-day mortality was 12.8%. The 5-year and 10-year survival rates were 45.6% and 23.5%, respectively. Twelve patients (1.8%) had redo aortic valve surgery. There was no difference in 30-day mortality or long-term survival between 2 age groups (> 65 yr v. ≤ 65 yr). Anemia and cardiopulmonary bypass (CPB) were independent risk factors for both longer hospital stay and reduced long-term survival. The impact of CPB pump time on mortality occurred mainly within the first 30 days after surgery. When CPB pump time extended beyond 170 minutes, there was a significant increase in 30-day mortality with further prolongation of CPB pump time, and the relationship between 30-day mortality and CPB pump time became approximately linear. Patients receiving dialysis have poor long-term survival with a very low rate of redo aortic valve surgery following SAVR with or without concomitant procedures. Older age (> 65 yr) is not an independent risk factor for either 30-day mortality or reduced long-term survival. Using alternative strategies to limit CPB pump time is an important way to reduce 30-day mortality.

Safety and Efficacy of Surgical Correction of Anomalous Aortic Origin of Coronary Arteries: Experiences from two Tertiary Cardiac Centers.

This study aims to describe the outcomes of surgical correction for anomalous aortic origin of coronary artery (AAOCA) with regard to symptom relief. We performed a retrospective multicentre study including surgical patients who underwent correction for AAOCA between 2009 and 2022. Patients who underwent concomitant cardiac procedures were also included. However, to analyze symptom relief we only assessed the subgroup of symptomatic patients who underwent isolated correction for AAOCA. A total of 71 consecutive patients (median age 55, range 12-83) who underwent surgical correction for AAOCA were included in the study. Right-AAOCA was present in 56 patients (79%), left-AAOCA in 11 patients (15%), single coronary ostium AAOCA in 4 patients (6%). Coronary unroofing was performed in 72% of the patients, coronary reimplantation in 28% and an additional neo-ostium patchplasty in 13% of the patients. In 39% of the patients a concomitant cardiac procedure was performed. During follow-up, no cardiovascular-related death was observed. Three patients (4.2%) had a myocardial infarction and underwent postoperative coronary artery bypass grafting. Six patients (8.5%) needed postoperative temporary mechanical circulatory support. Among the 34 symptomatic patients who underwent isolated AAOCA correction, 70% were completely asymptomatic after surgery, 12% showed symptom improvement and no symptom improvement was observed in 18% of the patients (median follow-up 3.5 years, range 0.3-11.1). Correction for AAOCA can be safely performed with or without concomitant cardiac procedures. Performing AAOCA correction leads to a significant improvement in symptoms for most patients.

Del nido versus conventional blood cardioplegia in patients with obstructive hypertrophic cardiomyopathy.

Myocardial protection is essential in cardiac surgery with cardiopulmonary bypass The Del Nido cardioplegia which was initially used in pediatric cardiac surgery, has been increasingly used in adult cardiac surgery recently. However, no literature has reported the efficacy of DNC in hypertrophic obstructive cardiomyopathy. This retrospective study involved elective patients who underwent extended surgical myectomy with or without concomitant cardiac surgical procedures between September 2017 and June 2022. Patients were distributed into two groups, the DNC and the CBC group. The primary outcome was high-sensitivity cardiac troponin I (hs-TnI) and creatine kinase-MB (CK-MB) levels at the 0, 1, and 2 postoperative days. The secondary outcomes contained: intraoperative LVEF, return to spontaneous rhythm; postoperative myocardial infarction, worsening or deteriorating of EF, mechanical circulatory support; new-onset atrial fibrillation; mechanical ventilation duration; intensive care unit hours; in-hospital days. Fifty-nine patients were included and divided into the CBC (n = 15) and the DNC group (n = 44). There was no statistical difference in patients' demographics and preoperative parameters between the two groups. No in-hospital mortality. The total cardioplegia volume [21.93(18.36,26.07) vs. 25.68(23.17,37.12), p = 0.012] and infusion times [1(1,1) vs. 2(2,3), p = 0.000] were less and the incidence of return to spontaneous rhythm after declamping was higher in the DNC group [97.7% vs. 73.3%, p = 0.013]. Postoperative hs-TnI and CK-MB levels were comparable between the two groups. A longer DNC infusion interval was associated with higher levels of CK-MB on postoperative day 1 and day 2 (p = 0.009 and p = 0.011, respectively). The use of DNC in extended surgical myectomy procedure was as safe and effective as CBC. However, DNC infusion interval over 60 minutes was associated with increased postoperative CK-MB levels.

Concomitant aortic root replacement during frozen elephant trunk implantation does not increase perioperative risk.

Our aim was to evaluate the risk of concomitant aortic root replacement during frozen elephant trunk (FET) total arch replacement. Between March 2013 and February 2021, 303 patients underwent aortic arch replacement using the FET technique. Patient characteristics, intra- and postoperative data were compared between patients with (n = 50) and without (n = 253) concomitant aortic root replacement (implantation of a valved conduit or using the reimplantation valve-sparing technique) after propensity score matching. After propensity score matching, there were no statistically significant differences in preoperative characteristics including the underlying pathology. There was no statistically significant difference regarding arterial inflow-cannulation or concomitant cardiac procedures, while cardiopulmonary bypass (P < 0.001) and aortic cross-clamp (P < 0.001) times were significantly longer in the root replacement group. Postoperative outcome was similar between the groups and there were no proximal reoperations in the root replacement group during follow-up. Root replacement was not predictive for mortality (P = 0.133, odds ratio: 0.291) in our Cox regression model. There was no statistically significant difference in overall survival (log rank: P = 0.062). Concomitant FET implantation and aortic root replacement prolongs operative times but does not influence postoperative outcomes or increase operative risk in an experienced high-volume centre. The FET procedure did not appear to be a contraindication for concomitant aortic root replacement even in patients with borderline indications for aortic root replacement.

CONTINUOUS FORMS OF INTRA-OPERATIVE ULTRAFILTRATION ENHANCE RECOVERY AFTER ADULT CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

CONTINUOUS FORMS OF INTRA-OPERATIVE ULTRAFILTRATION ENHANCE RECOVERY AFTER ADULT CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Complete Excision of Mitral Annular Calcification Can Be Achieved With a Low Mortality Risk

BackgroundMitral annular calcification (MAC) in mitral valve surgery constitutes a major challenge. Debridement with patch reconstruction of the mitral annulus facilitates valve repair or replacement, however, there is a perception that this procedure may elevate operative risk. This study sought to review a single-center experience with mitral annular debridement and patch reconstruction in patients with MAC. MethodsData were collected on patients operated on from January 2017 to December 2020 in the setting of significant MAC. Patients underwent a systematic approach to MAC excision, involving complete removal of the entire calcium bar. This was followed by patch reconstruction of the debridement area before either valve repair or replacement. ResultsThe investigators identified 38 patients (24 female, 12 male) whose median age was 72 years (interquartile range, 62-80 years). There were 14 mitral valve repairs and 24 replacements. Twenty-five patients underwent a concomitant cardiac procedure. Seven cases were redo sternotomies. There were 2 (5%) 30-day mortalities. Median length of intensive care unit stay was 2.4 days, and median hospital stay was 8.5 days. One patient required postoperative extracorporeal support. There were 4 late deaths. Actuarial survival at 1 and 2 years was 89% and 82%, respectively. No patient has required reoperation for valvular dysfunction. ConclusionsA systematic approach to MAC debridement, involving excision of the entire calcium bar and annular reconstruction, can be used in patients undergoing either isolated or combined complex mitral valve surgery. This strategy can be performed with a low risk of perioperative mortality despite relatively longer operative times.

Lung transplantation and concomitant cardiac surgical procedures: A systematic review and meta-analysis.

Lung transplantation is an effective treatment option for end-stage lung diseases. In some cases, these patients may also have underlying cardiac disease which may require surgical intervention before or during transplantation. Concomitant cardiac surgery may often be preferred, as reduced lung function precludes these patients from pre-transplant surgery. Our meta-analysis sought to examine the impact of lung transplantation paired with concomitant cardiac surgery on long-term mortality. We conducted a systematic review of the MEDLINE, Embase, and Cochrane databases. Our primary outcome was overall mortality. Secondary outcomes included length of stay (LOS) in hospital and serious postoperative complication rates. We used a meta-analytic model to determine the differences in the above outcomes between patients who underwent lung transplantation with or without concomitant cardiac surgery. Out of the 1876 articles screened, 7 met our pre-determined inclusion criteria. Lung transplantation with concomitant cardiac surgery was not associated with increased mortality compared to lung transplantation alone (hazard ratio = 1.02; 95% confidence interval [CI] = 0.80-1.31; I2 = 0%; p = .99). LOS in hospital was not significantly different between groups (standardized mean difference = 0.32; 95% CI = -0.91 to 1.55). Postoperative complication rates were also reported but not analyzed due to missing data. There was no significant difference in mortality rates in patients undergoing lung transplantation with or without concomitant cardiac surgery at 1, 3, and 5 years. However, postoperative complication rates were higher in the concomitant group. The decision to perform concomitant procedures should be tailored to each patient's clinical condition.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes

ObjectivesThere is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes. MethodsWe reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients. ResultsThe median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time. ConclusionsMechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Aortic valve replacement through minithoracotomy. Results from the Peruvian experience.

To assess mortality, major valve-related events (MAVRE), and other complications in the perioperative period and follow up in patients with aortic valve replacement (AVR) through mini-thoracotomy (MT). We retrospectively analyzed patients aged <80 who underwent AVR through MT between January 2017 and December 2021 in a national reference center in Lima, Peru. Patients undergoing other surgical approaches (mini-sternotomy, etc.), other concomitant cardiac procedures, redo, and emergency surgeries were excluded. We measured the variables (MAVRE, mortality, and other clinical variables) at 30 days and a mean follow-up of 12 months. Fifty-four patients were studied, the median age was 69.5 years, and 65% were women. Aortic valve (AV) stenosis was the main indication for surgery (65%), and bicuspid AV represented 55.6% of cases. At 30-days, MAVRE occurred in two patients (3.7%), with no in-hospital mortality. One patient had an intraoperative ischemic stroke, and one required a permanent pacemaker. No patient underwent reoperation due to prosthesis dysfunction or endocarditis. In a mean follow-up of one year, MAVRE occurrence did not show variations with the perioperative period, most patients remained in NYHA I (90.7%) or II (7.4%) compared to the preoperative period (p<0.001). AV replacement through MT is a safe procedure in our center for patients under 80 years.

Intraoperative Support for Primary Bilateral Lung Transplantation: A Propensity-Matched Analysis

BackgroundSingle-center studies support benefits of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a method of intraoperative support. Propensity-matched data from a large cohort, however, are currently lacking. Therefore, our goal was to compare outcomes of intraoperative VA-ECMO and cardiopulmonary bypass (CPB) during bilateral lung transplantation (LTx) with a propensity analysis. MethodsWe performed a retrospective analysis of 795 consecutive primary adult LTx patients (June 1, 2011-December 26, 2020) using no intraoperative support (n = 210), VA-ECMO (n = 150), or CPB (n = 197). Exclusion criteria included LTx on venovenous-ECMO, single/redo LTx, ex vivo lung perfusion, and concomitant solid-organ transplantation or cardiac procedure. Propensity analysis was performed comparing patients who underwent intraoperative CPB or VA-ECMO. ResultsThe propensity CPB group required more blood products at 72 hours (P = .02) and longer intensive care unit length of stay (P < .001) and ventilator dependence days (P < .001). There were no differences in cerebrovascular accident (P = 1), reintubation (P = .4), dialysis (P = .068), in-hospital mortality (P = .33), and 1-year (P = .67) and 3-year (P = .32) survival. The CPB group had a higher incidence of grade 3 primary graft dysfunction at 72 hours (P < .001). Neither support strategy was a predictor of 1- and 3-year mortality in our multivariable model (VA-ECMO, P = .72 and P = .57; CPB, P = .45 and P = .91, respectively). ConclusionsIntraoperative VA-ECMO during lung transplantation was associated with fewer postoperative blood transfusions, shorter length of mechanical ventilation, and lower incidence of a grade 3 primary graft dysfunction at 72 hours. Although there were some differences in the postoperative course between the VA-ECMO and CPB groups, support type was not associated with differences in survival.

Surgical management of transvenous lead-induced tricuspid regurgitation in adult and pediatric patients with congenital heart disease.

The objective of this study was to evaluate outcomes of surgical management of lead-induced tricuspid regurgitation (TR) in patients with congenital heart disease. We analyzed data of 54 consecutive patients who underwent tricuspid valve (TV) surgery from 1998 to 2015 for lead-induced TR. Primary end points, including mortality, TV reinterventions, and longitudinal TR measurements, were analyzed with the Kaplan-Meier method or with repeated measures proportional odds modeling. The median age of patients was 48.2years (interquartile range, 37.3-59.0years); 31 (57.4%) were female; 2 (3.7%) were children. Thirty patients (55.6%) underwent TV repair and 24 (44.4%) had replacement, and 52 underwent concomitant cardiac procedures. Thirty-day mortality was 1.9% (repair: 3.3%, replacement: 0.0%). Five-year survival was 80.4% overall and 79.7% and 81.4% for the repair and replacement groups, respectively. In response to surgery, TR improved in both groups (each P<.001) but more with replacement than repair (P<.001); longitudinal analysis showed that TR trends observed early on favoring replacement were sustained across follow-up (P<.001). The model-estimated risk of moderate or severe TR at 5-year follow-up, conditional on having severe preoperative TR, was 74.4% for the repair and 10.7% for the replacement group. Five-year cumulative risk of TV reintervention was comparable for valve repair and replacement. Despite the need for concomitant cardiac procedures in most of the patients, early mortality was low after TV surgery. Survival and rate of TV reintervention were comparable for the repair and replacement groups. However, TV repair was associated with progressive TR during intermediate follow-up, especially in patients with severe preoperative TR.

Transseptal versus left atrial approach for mitral valve surgery: postoperative need for pacemaker.

Concerns exist about higher rates of pacemaker implantation using the extended superior transseptal approach for mitral valve surgery. This study aims to compare the extended superior transseptal and the left atrial approach regarding the need for pacemaker implantation after mitral valve surgery. We performed a retrospective analysis of the data of patients undergoing mitral valve surgery through either a sternotomy and transseptal approach or a mini-thoracotomy and left atrial approach in a single centre in the period January 2010 to May 2021. The primary outcome was the evaluation of the postoperative pacemaker implantation rate. Overall, 677 patients were included, 333 with transseptal and 344 with left atrial approach, and 58 (8.6%) patients underwent pacemaker implantation postoperatively. There was no significant difference in the rate of pacemaker implantation between the 2 groups [overall: 34 (10.2%) vs 24 (7%), P = 0.133; for sinus node dysfunction: 12 (3.6%) vs 9 (2.6%), P = 0.459; for high-degree atrioventricular block: 22 (6.6%) vs 15 (4.4%), P = 0.199; transseptal vs left atrial approach, respectively]. A subgroup analysis of the relative effect of transseptal versus left atrial approach on the rate of postoperative pacemaker implantation revealed mitral replacement as a statistically significant confounder (P = 0.019). The exclusion of patients undergoing concomitant cardiac procedures did not lead to a statistically significant difference in the pacemaker implantation rate between the 2 approaches. The analysis of the data of these patients shows no significant difference in the rate of permanent pacemaker implantation between the extended superior transseptal and the left atrial approach for mitral valve surgery.

Long-Term Weaning of Mechanical Ventilation After Lung Transplantation: Patient Characteristics and Impact on Survival

<h3>Purpose</h3> Following lung transplantation (LTx), some recipients may require a prolonged postoperative course including long-term weaning of mechanical ventilation, raising concerns regarding transplant benefit. The aim of this study was to characterize this subgroup of patients, identify risk factors of prolonged mechanical ventilation (PMV), and determine impact on survival. <h3>Methods</h3> We retrospectively reviewed all adult LTx procedures performed at our center between January 2008 and January 2019 (n=1138). Logistic regression analysis of baseline characteristics and peri-operative variables was utilized to identify risk factors for PMV. The subgroup with PMV > 60 days was then compared to a random sample of patients of equal size with short MV (< 48 hr). <h3>Results</h3> Fifty-eight patients (5%) underwent PMV > 60 days (median 99.5, IQR 71-152 days). Independent risk factors for PMV > 60 days were bridging on MV, double (versus single) LTx, concomitant cardiac procedure, re-exploration for bleeding, and primary graft dysfunction higher grades. At time of LTx listing, the group with PMV > 60 days had higher lung allocation score (72 [44-89] vs 40 [35-48], p < .01), greater chest wall soft tissue to pectoralis muscle thickness ratio (3 ± 1 vs 2 ± 1, p = .02), lower 6-minute walk test distance (873 [680-1058] vs 1003 [821-1183], p = .03), increased bridging on MV (72% vs 53%, p = .03) or ECMO (29% vs 0%, p < .01), compared to patients with short MV (< 48 hr). The group with PMV > 60 days underwent more double LTx (93% vs 48%, p < .01), cardiopulmonary bypass utilization (93% vs 45%, p < .01), concomitant cardiac procedures (29% vs 5%, p < .01), re-exploration for bleeding (36% vs 3%, p < .01), delayed chest closure (52% vs 2%, p < .01), post-LTx ECMO (24% vs 0%, p < .01), and had higher primary graft dysfunction grade 3 (48% vs 2%, p < .01). Additionally, patients with PMV > 60 days had higher hospital mortality (15% vs 3%, p = 0.02) and lower 1-year survival (59% vs 86%, p < .01); however, there was no difference in 3- or 5-year survival. <h3>Conclusion</h3> LTx recipients who undergo long-term weaning of MV have unique baseline characteristics prior to listing that influence the likelihood of a prolonged perioperative course and worse short-, but not long-, term survival. Understanding the specific predictors of PMV, and which are potentially modifiable, would contribute to optimal recipient selection.

Mechanical Circulatory Support During Lung Transplantation: Choices, Outcomes and Impact of Duration

<h3>Purpose</h3> Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) has recently replaced cardiopulmonary bypass (CPB) as the method of choice for mechanical circulatory support during lung transplantation (LTx). The aim of this study was to compare the outcomes of using ECMO versus CPB and examine the impact of its duration in a contemporary LTx cohort. <h3>Methods</h3> Between January 2017, and January 2020, 379 LTx were performed at our center. CPB was utilized in 111 and VA ECMO in 33 cases (unmatched cohort). After exclusion of patients who underwent concomitant cardiac procedures or retransplantation (all were in CPB group), the 33 VA ECMO patients were matched to CPB patients with a 1:2 ratio based on primary diagnosis, LTx type (bilateral or single), age, lung allocation score, body mass index, donor type (brain death or cardiac death), and duration of mechanical circulatory support. <h3>Results</h3> In the unmatched cohort, CPB group had a significantly higher incidence of re-exploration for bleeding and hospital mortality compared to ECMO group (15.3% vs 3.0%, <b>p = .047</b>; 10.8% vs 0%, <b>p = .038</b>, respectively). There were no statistically significant differences between CPB and ECMO groups in ICU stay, hospital stay, incidence of primary graft dysfunction (PGD) at 72 hours, postoperative tracheostomy, post-transplant ECMO use, re-admission, or 1-year survival. In the matched cohort, the differences between CPB and ECMO groups in both incidence of re-exploration for bleeding or hospital mortality were found to be statistically insignificant (13.6% vs 3.0%, <i>p</i> = .092; 7.6% vs 0%, <i>p</i> = .125, respectively). The differences between both groups in the other outcome endpoints remained insignificant. In the CPB group, patients with higher grades of PGD at 72 hours had significantly longer duration of CPB (PGD 0, 1, 2, 3 median 217, 209, 250, 289 minutes, <b>p = .014</b>, respectively). In the ECMO group, there were no differences in duration of ECMO between patients with different PGD grades. <h3>Conclusion</h3> Despite having a significantly higher incidence of re-exploration for bleeding and hospital mortality in CPB group in the unmatched cohort, there were no statistically significant differences between the two groups in the studied outcomes in the matched cohort, although there were strong trends. Notably, longer CPB time was associated with higher PGD grades whereas time on ECMO was not associated with PGD grades.