Longer Cross-clamp Times Research Articles

Prophylactic Left Atrial Appendage Ligation During CABG: A Propensity Score-Matched Analysis

To evaluate short-term outcomes and statewide practice patterns of prophylactic left atrial appendage ligation (P-LAAL) in coronary artery bypass grafting (CABG) patients without pre-operative atrial fibrillation (AF). Adult patients who underwent an on-pump CABG (2017 - 2023) within a regional collaborative were identified. Patients with a history of AF, previous cardiac surgery, or non-device based LAAL were excluded. Patients were stratified by LAAL status and were propensity score matched. Univariable analysis was used to compare short-term clinical outcomes. Of 16,547 patients examined, 442 underwent P-LAAL. The propensity score matched cohort (439 P-LAAL, 439 No P-LAAL) was compared and had no significant differences in pre-operative CHA2DS2-VASc scores or operative variables. The P-LAAL group had longer cross clamp time (82 vs 76 minutes, p=0.001), ICU hours (72 vs 66, p=0.001), length of stay (6.0 vs 6.0 days, p=0.010), increased post-operative AF (35% vs 24%, p<0.001), and more discharge on anticoagulation (17% vs 8.2%, p<0.001). There were no significant differences in post-operative stroke (1.1% vs 2.1%, p=0.423), readmission (13% vs 9.6%, p=0.118), operative mortality (2.5% vs 1.6%, p=0.480), or readmission for thrombotic or bleeding complications (0.7% vs 1.1%, p=0.724). Hospitalization costs were significantly higher for P-LAAL patients ($43,478 vs $40,645, p<0.001). The rate of P-LAAL during CABG increased from 1.61% (2017) to 5.65% (2023) (p<0.001). Despite higher rates of post-operative AF, discharge on anticoagulation, and hospitalization costs in patients undergoing P-LAAL during CABG, there was no difference in short-term clinical endpoints including stroke and operative mortality.

Effect of Shorter Cross Clamp Time vs. longer Cross Clamp time on cardiac enzyme levels in pts of CAD undergoing CABG

Aim: To compare mean cardiac enzyme levels in of shorter cross clamp time V/S longer cross Clamp time in patients undergoing CABG in local population. Study Design: Randomized Controlled Trial Place and duration: This study was performed from 2nd April 2020 to 2nd October 2020 in the Department of Cardiac Surgery Punjab Institute of Cardiology, Lahore. Methodology: After informed consent, all patients undergoing CABG were enrolled and divided into two groups. A predesigned performa was used to enter preop, intra op and post op variables and cardiac enzyme levels were compared between shorter (&lt;60 minutes) and longer (&gt;60 minutes) aortic cross clamp time groups. Results: Study had enrolled 300 patients and 150(50%) patients were designated group A (shorter cross clamp time and 150 (50%) patients were designated in group B (longer cross clamp time). Out of these 300, 246 patients (82%) were males and 54 (18%) were females. Extremes of age were 70 years and 37 years and mean age was 56.77±8.03 years. Group A (shorter cross clamp time) patients had mean age of 56.64 ±7.53 and group B (longer cross clamp time) patients had 56.89±8.52 .Mean EF (%) was 52.17±8.98 with 23% being minimum and 70% being maximum. In group A patients, 93 patients (62%) were hypertensive , 82(55%) were smokers and 67 (45%) patients were diabetic, while group B had 110 (73%) hypertensive, 84(56%) smokers and 73(49%) diabetic patients. Mean CPB time in group A was recorded to be 93.72±29.97 and mean CPB time in group B was 121.04±31.83. The P-value was 0.001, significant enough to represent difference in CPG time in both groups Practical Implication: Additionally, no notable difference was found in need of inotropic supports between two groups. Longer cross clamp time is also associated with longer CPB time which in turn correlates with higher morbidity and mortality. Conclusion: It is concluded that prolonged cross clamp time is an independent predictor of morbidity despite cardio protection by modern strategies Keywords: CKMB, IABP, CABG, CPB time, aortic cross clamp time, Shorter Cross

Independent associations with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms

ObjectiveWe aimed to identify outcomes and factors that independently associate with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms, defined as aneurysms confined to the segment below the diaphragm. MethodsThis retrospective analysis included 721 extent IV thoracoabdominal aortic aneurysm repairs performed in our institution from 1986 to 2021. Indications for repair were aneurysm without dissection in 627 cases (87.0%) and aortic dissection in 94 cases (13.0%). Overall, 466 patients (64.6%) were symptomatic preoperatively; 124 (17.2%) procedures were performed in patients with acute presentation, including 58 (8.0%) ruptured aneurysms. ResultsOperative death occurred after 49 (6.8%) repairs. Persistent renal failure necessitating dialysis occurred after 43 (6.0%) repairs. Binary logistic regression modeling revealed that previous extent II thoracoabdominal aortic aneurysm repair, chronic kidney disease, previous myocardial infarction, urgent or emergency repair, and longer crossclamp times during surgery were independently associated with operative mortality. Among early survivors (n = 672), competing risk analysis revealed that cumulative incidence of mortality and reintervention rates at 10 years were 74.8% (95% confidence interval, 71.4%-78.5%) and 3.3% (95% confidence interval, 2.2%-5.1%), respectively. ConclusionsAlthough patient comorbidities contributed to operative mortality, factors associated with the repair, such as urgent or emergency status, the duration of aortic crossclamping, and certain types of complex reoperation, also played prominent roles. Patients who survive the operation can expect a durable repair that usually is free from late reintervention. Expanding our collective knowledge regarding patients who undergo open repair of extent IV thoracoabdominal aortic aneurysms will enable clinicians to establish best practices and improve patient outcomes.

Acute kidney injury after arterial switch operation: incidence, risk factors, clinical impact – a retrospective single-center study

Background This retrospective study aimed to determine the incidence, risk factors, and outcomes of acute kidney injury (AKI) in neonates following the arterial switch operation (ASO) for transposition of great arteries (TGA). Methods Retrospective review of medical data of children who underwent ASO in 2019–2020 in the Ukrainian Children’s Cardiac Center. Results 76 consecutive neonatal patients were included, 48 developed AKI after ASO (51.7%), and 24 – had severe AKI (25.8%). Severe AKI development was associated with longer cross-clamp time: 82 (61–127) versus 73.5 (53–136) in the non-severe AKI group (p = 0.02). 76 min of cross-clamp time were defined as a threshold value for increased severe AKI risk, OR 4.4 (95% CI: 1.5 – 13, p = 0.01). Higher lactate levels during cardiopulmonary bypass (CPB) increased severe AKI development risk, OR 1.5 (95% CI: 1.0 − 2.0, p = 0.03). Children with severe AKI had prolonged mechanical ventilation, longer time to negative fluid balance, and higher postoperative day 3 (POD3) Inotropic Score (IS). Only one patient required peritoneal dialysis. Conclusions In our study, 51.7% of patients developed AKI after ASO, 25.8%–severe AKI. Prolonged cross-clamp time and higher lactate levels during cardiopulmonary bypass increased the risk for severe AKI development. The development of AKI was associated with prolonged mechanical ventilation, longer time to negative fluid balance, higher POD 3 Inotropic Score.

Robotic vs other surgery techniques for mitral valve repair and/or replacement: A systematic review and meta-analysis

ObjectiveMitral valve repair or replacement (MVr/R) are procedures that aim to correct mitral regurgitation. The three techniques, namely conventional, minimally invasive, and robotic each present their advantages and setbacks. Previous studies had compared each technique with the other but mostly focused on two techniques. In this systematic review and meta-analysis, we attempt to compare all three techniques, to provide a reference for the clinical selection of the best surgical scheme. MethodsThe literature search was performed in databases including PubMed, Scopus, Google Scholar, EBSCOHost, Wiley, ProQuest, and Embase, up to June 1st, 2022. Critical appraisal of studies was performed using Newcastle Ottawa Scale converted by Agency for Healthcare Research and Quality (AHRQ). We used bayesian network meta-analysis and conventional meta-analysis (random effects model) to rank and analyze pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). Forest plots of pooled effect estimates comparing each treatment and ranking panel using Surface Under the Cumulative Ranking (SUCRA) were used for the intervention measures. ResultsA total of 18 studies with 60,331 patients were included in this systematic review and meta-analysis. Hospital stay was significantly lower in the group with robotic procedure compared to the conventional interventions in terms of ICU stay and overall length of stay. The mean difference of length of hospital stay days of the conventional group was 2.27 (1.31–3.30) days and of the minimally invasive −0.364 (−2.31–1.53) days compared to the robotic group. The robotic procedure was associated with longer cross-clamp and cardiopulmonary bypass (CPB) times. Nevertheless, the robotic procedure was associated with lower infection (OR = 0.60 [95% CI 0.50–0.73)] rates and in-hospital mortality compared to conventional techniques (OR=0.53 [95% CI 0.40–0.70)] but not the minimally invasive techniques (OR = 1.74 [95% CI 0.48–6.31]). ConclusionRobotic surgery showed more favorable surgical outcomes, including hospital stay, post-operational complications and in-hospital mortality, although it was associated with longer cross-clamp time and CPB time compared to other interventions. However, its high cost is a difficult consideration for its widespread clinical implementation.

Robotic vs. minimally invasive mitral valve repair: A 5-year comparison of surgical outcomes.

Minimally invasive mitral valve repair (MVr) is commonly performed. Data on the outcomes of robotic MVr versus nonrobotic minimally invasive MVr are lacking. We sought to compare the short-term and mid-term outcomes of robotic and nonrobotic MVr. We reviewed all patients who underwent robotic MVr (n = 424) or nonrobotic MVr via right mini-thoracotomy (n = 86) at Mayo Clinic, Rochester, MN, from January 2015 to February 2020. Data on baseline and operative characteristics, operative and long-term outcomes were analyzed. Patients were matched 1:1 using propensity scores. Sixty-nine matched pairs were included in the study. The median age was 59 years (interquartile range[IQR]: 54-69) and 75% (n = 103) were male. Baseline characteristics were similar after matching. Robotic and nonrobotic MVr had similar operative characteristics, except that robotic had longer cross-clamp times (57 [48-67] vs. 47 [37-58] min, p < .001) and more P2 resections (83% vs. 68%, p = .05) compared to nonrobotic MVr. There was no difference in operative outcomes between groups. Hospital stay was shorter after robotic MVr (4 [3-4] vs. 4 [4-6] days, p = .003). After a median follow-up of 3.3 years (IQR, 2.1-4.5), there was no mortality in either group, and there was no difference in freedom from mitral valve reoperations between robotic and nonrobotic MVr (5 years: 97.1% vs. 95.7%, p = .63). Follow-up echocardiogram analysis predicted excellent freedom from recurrent moderate-or-severe mitral regurgitation at 3 years after robotic and nonrobotic MVr (90% vs. 92%, p = .18, respectively). Both short-term and mid-term outcomes of robotic and nonrobotic minimally invasive mitral repair surgery are comparable.

The effect of cardiac surgery type on incidence of post-operative atrial fibrillation amongst patients with post-procedural conduction disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Approximately 1% of cardiac operations result in post-operative heart block (PoHB). Post -operative atrial fibrillation (PoAF) has been quoted as occurring in 40-50% of combined coronary artery bypass graft (CABG) and valvular procedures, 25% of CABG only and 30% of valve only procedures. The co-existence of PoAF in patients with PoHB, and the link to operation type is less well documented. Purpose To investigate characteristics predisposing patients post cardiac surgery for PoHB and PoAF. Methods We screened patients who had undergone CABG, aortic or mitral valve replacements (AVR and MVR respectively) or mitral valve repairs at Bristol Royal Infirmary between 1/1/2010 and 1/4/2020. We created a merged surgical and electrophysiological database identifying patients with permanent pacemakers inserted within 30 days of cardiac surgery for PoHB to create our final database. By reviewing electronic notes we identified patients in this cohort who developed PoAF prior to discharge. We excluded patients with congenital heart defects or known prior atrial fibrillation. We then analysed the incidence of both PoHB and PoAF for different operation subtypes. Results Of the 10779 operations, 6625 (61%) were CABG-Only, 4124 (38%) were Valve-Only and 1219 (11%) were combined CABG&amp;Valve. In total 85 (0.8%) patients developed PoHB. There was a higher proportion of female patients in the PoHB group but no other demographic differences (See Table 1). In terms of operation type, the PoHB group contained a significantly higher proportion of patients who had undergone AVR (78% vs. 28%, p&amp;lt;0.001). There was also a significant association with operations performed on cardiopulmonary bypass and with longer cross clamp time however this did not remain statistically significant on multivariate analysis. Valve surgery was associated with a higher proportion of patients developing PoHB than CABG, with AVR relating to the highest PoHB rates (AVR 2.0%, MVR 0.9%, CABG 0.2%, p&amp;lt;0.0001). Both mechanical and bioprosthetic AVR were associated with a higher proportion of patients developing PoHB than MVR. In our cohort 34/85 (41%) patients with POHB developed post-operative AF. After univariate analysis of the patient and operation factors listed in Table 1, only age and body mass index were predictors of development of PoAF after multivariate analysis (age: odds ratio 1.81 (1.02-1.36), p=0.024, BMI: odds ratio 1.09 (1.02-1.17), p=0.01), with no association to surgical parameters. Conclusion PoHB occurs commonly following both CABG and valve procedures, with higher incidence in the setting of valve surgery, with our data showing a 2 fold higher chance of PoHB in patients undergoing aortic versus mitral valve replacements. In contrast, there is no clear relationship between type of surgery and development of postoperative atrial fibrillation in this cohort but larger studies are warranted.

Prediction of temporary epicardial pacing wire use in cardiac surgery.

Placement of temporary epicardial pacing wires (TEPW) at the end of open heart surgery cases is routine but can be associated with complications. Identification of patients who are high risk for requiring pacing would be beneficial on guiding selective TEPW placement. The purpose of this study was to identify predictors of temporary pacing immediately post cardiac surgery. A retrospective analysis of patients undergoing cardiac surgery from 2005 to 2016 at the Maritime Heart Center was conducted. Analysis was performed of patients who require pacing on arrival to the cardiovascular intensive care unit (CVICU) compared with those who were not paced. Multivariable logistic regression was used to determine each variable's risk adjusted likelihood of pacing for the entire cohort. Subgroup analysis was performed in the isolated procedures. A total of 11 752 patient underwent surgery from the year 2005 to 2016. Two thousand and fifty-one (17.5%) required pacing on arrival to CVICU. Older age, female sex, preoperative renal failure, lower ejection fraction (EF), preoperative arrhythmia, preoperative use of calcium channel blockers, and longer cross-clamp times were risk factors for pacing. In the isolated coronary artery bypass grafting and aortic valve replacement groups, findings were similar to the overall cohort. Only age, obesity, and chronic obstructive pulmonary disease were risk factors for pacing in the isolatedmitral valve (MV) repair group and only preoperative arrhythmia in the isolated MV replacement group. We have identified risk factors for TEPW use following cardiac surgery and in isolated procedure subgroups. These risk factors may help guide selective TEPW placement.

Comparison of Custodiol® and modified St. Thomas cardioplegia for myocardial protection in coronary artery bypass grafting

Background/Aim. Custodiol? is a hyperpolarizing cardioplegic solution which has been used in our national cardiac surgical practice exclusively for the heart transplant surgery. Owing to its numerous advantages over the standard depolarizing solutions, Custodiol? became cardioplegic solution of choice for all other cardiac surgical procedures in many cardio-surgical centers. This study evaluated myocardial protection by Custodiol? compared to modified St. Thomas cardioplegic solution in coronary artery bypass surgery. Methods. In a prospective four-month study, 110 consecutive adult patients who underwent primary isolated elective on-pump coronary artery bypass grafting (CABG) were randomized into the Custodiol? group (n = 54) and the St. Thomas groupa (n = 50), based on the type of administered cardioplegia; six patients were excluded. Cardiac protection was achieved as antegrade cold crystalloid cardioplegia by one of the solutions. Myocardial preservation was assessed through following outcomes: spontaneous rhythm restoration post cross-clamp, and postpoperative cardiac specific enzymes level, ejection fraction (EF) change, inotropic support, myocardial infarction (MI), atrial fibrillation (AF), and death. Results. Preoperative and intraoperative characteristics of patients in both groups were similar except for a considerably longer cross-clamp time in the Custodiol? group (49.1 ? 19.0 vs. 41.0 ? 12.9 minutes; p = 0.022). The Custodiol? group exhibited a higher rate of return to spontaneous rhythm compared to the St. Thomas group (31.5% vs. 20.0%, respectively; p = 0.267), lower rates of AF (20.4% vs. 28%, respectively; p = 0.496), MI (1.8% vs. 10.0%, respectively; p = 0.075) and inotropic support (9.0% vs. 12.0%, respectively; p = 0.651), albeit not statistically significant. There was an insignificant difference in peak value of troponin I between the Custodiol? and Thee St. Thomas group (5.0 ? 3.92 ?g/L vs. 4.5 ? 3.39 ?g/L, respectively; p = 0.755) and creatine kinase-MB (26.9 ? 15.4 ?g/L vs. 28.5 ? 24.2 ?g/L, respectively; p = 0.646) 6 hours post-surgery. EF reduction was comparable (0.81% vs. 1.26%; p = 0.891). There were no deaths in both groups. Conclusions. Custodiol? and modified St.Thomas cardioplegic solution have comparable cardioprotective effects in CABG surgery. The trends of less frequent MI, AF and ino-tropic support, despite the longer cross-clamp time in the Custodiol? group may suggest that its benefits could be ascertained in a larger study.

Del Nido cardioplegia in isolated adult coronary artery bypass surgery

BackgroundDel Nido cardioplegia (DC) offers prolonged single-dose myocardial protection in pediatric cardiac surgery. We set out to evaluate the efficacy of DC in adult patients undergoing isolated coronary artery bypass grafting (CABG). MethodsFrom January 2012 to October 2017, 851 consecutive isolated CABG surgeries were performed by 2 study surgeons at our center with blood cardioplegia (BC, n = 350), used from January 2012 to April 2014, and DC (n = 501), used from May 2014 to October 2017. Propensity matching was used to yield 325 well-matched pairs. Clinical data were extracted from our local Society of Thoracic Surgeons database and mortality data from the Michigan State Social Security Death Index. ResultsSingle-dose administration was used in 83% (417/501) of patients receiving DC. In propensity-matched groups, postoperative median troponin T levels (0.28 [0.16-0.59] ng/mL vs 0.46 [0.27-0.81] ng/mL; P < .01) were lower for patients receiving DC, and no difference in ejection fraction on postoperative echocardiography was observed (54 ± 12% and 53 ± 13% for BC and DC, respectively; P = .36). Perioperative outcomes were similar except for greater rate of atrial fibrillation (33% vs 23%; P = .01) in the DC group. Subgroup analyses revealed equivalent myocardial protection and clinical outcomes in patients with age ≥75 years, left ventricular ejection fraction ≤35%, left main disease, or Society of Thoracic Surgeons score ≥2.5%. Four-year survival did not differ between patients undergoing BC or DC. ConclusionsThe current study revealed noninferior myocardial protection and clinical outcomes with DC versus BC in both routine and greater-risk patients undergoing isolated CABG. DC demonstrated the feasibility of single-dose administration for isolated CABG surgery. Larger randomized studies are needed to further explore the safety and efficacy of DC in adult cardiac surgery with longer crossclamp times.

Surgery on the Failing Aortic Homograft: A Changing Paradigm?

Since the establishment of the Sydney Heart Valve Bank at St Vincent's Hospital in 1991, there have been over 150 aortic homograft implants. Homografts account for <1% of aortic valve replacements (AVR). Currently, the main indication is acute infective endocarditis with perivalvular abscess. Over a decade ago, a significant number of homografts were implanted in young patients with congenital aortic valve disease, aiming to avoid anticoagulation and potentially provide a prosthesis with good durability. Unfortunately, homografts develop severe calcification and structural deterioration (or endocarditis) requiring redo cardiac surgery. Re-operation can be technically demanding. This presentation reviewed redo aortic valve surgery in aortic homografts. Eleven patients were identified: eight redo Bentall operations and three redo AVR with sutureless valves. The redo Bentalls operations were performed until 2016, and patients were almost 100 minutes longer on cardiopulmonary bypass and had 1 hour longer cross clamp time than the sutureless valves. There were two deaths, both from the Bentalls group. Sutureless AVR patients had a shorter intensive care unit and overall hospital length of stay. Sutureless valve implant was more likely in the current era (2017 onwards). With the development of sutureless valves, surgeons now can potentially avoid root replacement surgery for the calcified homograft. Transcatheter aortic valve implantation for the degenerated aortic homograft may be an option in the future; however, due to the high concomitant procedure rate (coronary or mitral disease, endocarditis) in this ‘young’ group, no patients were suitable.

Efficacy of Aortic Valve Replacement through Full Sternotomy and Minimal Invasion (Ministernotomy).

Background: new minimally invasive sternotomy (mini-sternotomy) procedures have improved the treatment outcome and reduced the incidence of perioperative complications leading to improved patient satisfaction and a reduced cost of aortic valve replacement in comparison to the conventional median sternotomy (full sternotomy). The aim of this study is to compare and gain new insights into operative and early postoperative outcomes, long-term postoperative results, and 5-year survival rates after aortic valve replacement through a ministernotomy and full sternotomy. Methods: This is a retrospective study of patients who underwent an isolated replacement of the aortic valve via a full sternotomy or ministernotomy from 2011 to 2016. From 2011 to 2016, 426 cardiac interventions were performed, 70 of which (16.4%) were of the ministernotomy and 356 (83.6%) of the full sternotomy. Through propensity score matching, 70 patients who underwent the ministernotomy (ministernotomy group) were compared with 70 patients who underwent the full sternotomy (control group). Results: in the propensity matching cohort, no statistical difference in operative time was noted (p = 0.856). The ministernotomy had longer cross clamp (88.7 ± 20.7 vs. 80.3 ± 24.6 min, p = 0.007) and bypass (144.0 ± 29.9 vs. 132.9 ± 44.9 min, p = 0.049) times, less ventilation time (9.7 ± 1.7 vs. 11.7 ± 1.4 h, p < 0.001), shorter hospital stay (18.3 ± 1.9 vs. 21.9 ± 1.9 days, p = 0.012), less 24-h chest tube drainage (256.2 ± 28.6 vs. 407.3 ± 40.37 mL, p < 0.001), fewer corrections of coagulopathy (p < 0.001), fewer patients receiving catecholamine (5.71 vs. 30.0%, p < 0.001) and better cosmetic results (p < 0.001). Moreover, the number of patients without complaints at 1 year after the operation was significantly greater in the ministernotomy group (p = 0.002), and no significant differences in the 5-year survival between the groups were observed. In the overall cohort, the ministernotomy had longer cross clamp times (88.7 ± 20.7 vs. 79.9 ± 24.8 min, p < 0.001), longer operative times (263.5 ± 62.0 vs. 246.7 ± 74.2 min, p = 0.037) and bypass times (144.0 ± 29.9 vs. 132.7 ± 44.5 min, p = 0.026), lower incidence of 30-day mortality (1(1.4) vs. 13(3.7), p = 0.022), shorter hospital stays post-surgery p = 0.025, less 24-h chest tube drainage, p < 0.001, and fewer corrections of coagulopathy (p < 0.001). Conclusions: the ministernotomy has a number of advantages compared with the full sternotomy and thus could be a better approach for aortic valve replacement.

Long-term survival after the Fontan operation: Twenty years of experience at a single center

ObjectiveExisting studies of patients palliated with the Fontan operation are limited by heterogeneous patient populations and incomplete follow-up. This study aimed to describe long-term post-Fontan survival in a modern patient cohort. MethodsAll 773 patients who underwent a first Fontan operation at our institution between 1992 and 2009 were reviewed. The primary outcome was the composite endpoint of Fontan takedown, heart transplantation, or death before 2013. ResultsFollow-up rate was 99.2%. Survival with intact Fontan circulation was 94% at 1 year (95% confidence interval [95% CI], 92%-95%), 90% at 10 years (95% CI, 88%-92%), 85% at 15 years (95% CI, 82%-88%), and 74% at 20 years (95% CI, 67%-80%). Distinct risk factors were identified for early (≤1 year) and late composite outcomes. Independent risk factors for early outcome included prolonged pleural drainage (hazard ratio [HR], 4.4; P < .001), intensive care unit stay >1 week (HR, 2.4; P < .001), Fontan before 1997 (HR, 3.3; P < .001), preoperative atrioventricular valve regurgitation (HR, 2.0; P < .001), and longer crossclamp time (HR, 1.3 per 10 minutes; P < .001). Late outcome was predicted by atrioventricular valve regurgitation prior to Fontan (HR, 2.0; P ≤ .001), and post-Fontan ICU stay >1 week (HR, 2.4; P < .001). ConclusionsLong-term mortality after Fontan operation remains substantial. Risk factors for death or loss of Fontan circulation differ between the early and late postoperative periods. Long-term survival has not improved appreciably over the last decade, suggesting that alternatives to the Fontan are warranted.

Right ventricular function following surgical aortic valve replacement and transcatheter aortic valve implantation: A cardiovascular MR study

ObjectiveThe response of the RV following treatment of aortic stenosis is poorly defined, reflecting the challenge of accurate RV assessment. Cardiovascular magnetic resonance (CMR) is the established reference for imaging of RV volumes, mass and function. We sought to define the impact of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) upon RV function in patients treated for severe aortic stenosis using CMR. MethodsA 1.5T CMR scan was performed preoperatively and 6months postoperatively in 112 (56 TAVI, 56 SAVR; 76±8years) high-risk severe symptomatic aortic stenosis patients across two UK cardiothoracic centres. ResultsTAVI patients were older (80.4±6.7 vs. 72.8±7.2years, p<0.05) with a higher STS score (2.13±0.73 vs. 5.54±3.41%, p<0.001). At 6months, SAVR was associated with a significant increase in RV end systolic volume (33±10 vs. 37±10ml/m2, p=0.008), and decrease in RV ejection fraction (58±8 vs. 53±8%, p=0.005) and tricuspid annular plane systolic excursion (22±5 vs. 14±3mm, p<0.001). Only 4 (7%) SAVR patients had new RV late gadolinium hyper-enhancement with no new cases seen in the TAVI patients at 6months. Longer surgical cross-clamp time was the only predictor of increased RV end systolic volume at 6months. Post-TAVI, there was no observed change in RV volumes or function. Over a maximum 6.3year follow-up, 18(32%) of TAVI patients and 1(1.7%) of SAVR patients had died (p=0.001). On multivariable Cox analysis, the RV mass at 6m post-TAVI was independently associated with all-cause mortality (HR 1.359, 95% CI 1.108–1.666, p=0.003). ConclusionsSAVR results in a deterioration in RV systolic volumes and function associated with longer cross-clamp times and is not fully explained by suboptimal RV protection during cardiopulmonary bypass. TAVI had no adverse impact upon RV volumes or function.

Conduction disorders after tricuspid annuloplasty with mitral valve surgery: Implications for earlier tricuspid intervention

ObjectiveTricuspid valve repair has been recently advocated in patients undergoing mitral valve surgery who have mild to moderate secondary tricuspid regurgitation. However, the incidence of heart conduction disorders after combined mitral valve and tricuspid valve interventions has not been evaluated. We sought to analyze the incidence of permanent pacemaker implantations and heart conduction disorders in patients undergoing mitral valve surgery with and without tricuspid valve annuloplasty. MethodsIn 2011 and 2012, among 201 consecutive patients referred to the Hôpital Européen Georges Pompidou for isolated nonischemic mitral valve disease, 113 underwent an isolated mitral valve procedure (group 1) and 88 had a concomitant tricuspid valve ring annuloplasty (group 2). ResultsPatients' mean age was 59.7 ± 16.5 years in group 1 and 60.7 ± 14.9 years in group 2 (P = .5). Mean crossclamp time and bypass time were 78 ± 35 minutes and 105 ± 47 minutes in group 1 and 92 ± 36 minutes and 128 ± 50 minutes in group 2, respectively (P = .001 and .005, respectively). Operative mortality was 3% (2.7% in group 1 and 3.2% in group 2, P = .4). Incidence of high-grade heart conduction disorders lasting more than 3 days postoperatively was 14.5% in group 1 and 41.2% in group 2 (P = .001). At 3 years, freedom from permanent pacemaker implantation was 99% ± 2% in group 1 and 94.1% ± 5% in group 2 (P = .02). For the entire cohort, longer crossclamp time (P = .02) and tricuspid ring annuloplasty (hazard ratio, 3.8; P = .001) were independent predictors of heart conduction disorders. ConclusionsThe need for permanent pacemaker implantation is increased after concomitant tricuspid ring annuloplasty in the setting of mitral valve surgery. A clinical period of observation up to 14 days after postoperative heart conduction disorders should be observed before recommending permanent pacemaker placement.

Bilateral Internal Mammary Artery Use for Coronary Artery Bypass Grafting Remains Underutilized: A Propensity-Matched Multi-Institution Analysis

Bilateral internal mammary arterial (BIMA) grafts have repeatedly demonstrated superior outcomes compared with single IMA (SIMA) after coronary artery bypass grafting (CABG). Despite known survival benefits with BIMA use, perceived perioperative challenges often preclude BIMA use. We hypothesized that the use of BIMA remains underutilized, even in low-risk patients. A total of 43,823 primary, isolated CABG patients in a regional Society of Thoracic Surgeons Database were evaluated. Patients were stratified by BIMA versus SIMA use. Surgical candidates considered "low risk" for BIMA use included the following: age less than 70 years; no or mild chronic lung disease; body mass index less than 30; and absence of diabetes. The BIMA patients (n = 1,333) were 1:1 propensity matched to SIMA patients (n = 1,333) and outcomes were compared. Overall, BIMA use was 3%; 24% (n = 10,327) of patients met "low-risk" criteria for BIMA use. Among "low-risk" patients, BIMA utilization was 6%. Propensity-matched comparisons revealed similar preoperative risk profiles between BIMA and SIMA patients (Predicted Risk of Mortality [PROM] 1.1% vs 1.1%, p > 0.05). The BIMA use was associated with longer cross-clamp time (71 vs 62 minutes, p < 0.05). Importantly, BIMA use was not associated with increased postoperative mortality, morbidity, or hospital length of stay (all p > 0.05). However, hospital readmission within 30 days was 41% greater for BIMA patients compared with SIMA patients (p = 0.01). Bilateral IMA graft use appears to remain underutilized in the modern surgical era, even in low surgical risk patients. The BIMA use does not appear to increase the risk of postoperative morbidity, although requires longer operative times and a higher risk for readmission. Efforts to more clearly understand surgeon motivators for the use of BIMA grafting are needed.

Clinical impact of left atrial appendage resection versus preservation during surgical ablation of atrial fibrillation

IntroductionResection of left atrial appendage (LAA) during surgical ablation of atrial fibrillation may decrease the incidence of postoperative cerebrovascular events and increase the induction and maintenance of sinus rhythm (SR). This study evaluates the effect of LAA resection after the surgical ablation of atrial fibrillation. Materials and methodsA retrospective analysis was made of 599 patients who underwent surgical myocardial revascularization and/or valve surgery with concomitant surgical ablation of atrial fibrillation. The LAA was resected in 140 patients and preserved in 459 patients. Postoperative, 1-month and 1-year results were compared between the groups in terms of TIA/CVA, maintenance of sinus rhythm, pacemaker dependence and mortality. ResultsThe patients who underwent LAA resection were older, had more frequent persistent AF and underwent more frequently biatrial ablation set. In this group, longer times of extracorporeal circulation and longer cross-clamp times were observed. During the follow-up period, the resection group has shown lower incidence of TIA/CVA and the overall mortality was also lower in this group of patients. ConclusionThe resection group in our study has shown the trend toward lower incidence of TIA/CVA and statistically significant decrease of overall mortality. This finding can support routine LAA resection during surgical ablation of atrial fibrillation.

A time-related parametric risk factor analysis for postoperative atrial fibrillation after heart surgery

Multiple mechanisms may be involved in postoperative atrial fibrillation. Therefore, our objective was to determine the risk factors for postoperative atrial fibrillation as a function of time after coronary artery bypass grafting or valve surgeries to determine which risk factors might predominate at different times. Parametric hazard functions were determined for 1583 patients and then in subgroups (coronary artery bypass grafting alone, mitral valve procedure, and aortic valve replacement +/- coronary artery bypass grafting). Multivariable risk factor analyses were performed, and the risk for postoperative atrial fibrillation was estimated. The risk for postoperative atrial fibrillation for all patients was highest immediately postoperatively and at 48 hours. The initial peak risk declined to approximately zero within 18 hours postoperatively. A second peak occurred at 48 hours, followed by a slow decline over the following 4 to 7 days. The time intervals encompassing these peaks were termed phase I and phase II. Predominant risk factors in phase I were older age (relative risk [RR], 1.6; P = .006), longer crossclamp time (RR, 1.3; P = .001), and mitral valve procedure (RR, 2.5; P = .0001). In phase II, these were older age (RR, 3.0; P < .0001), greater weight (RR, 1.6; P < .0001), and Caucasian race (RR, 2.5; P = .006). For patients receiving a mitral valve procedure, the risk for postoperative atrial fibrillation in phase II was higher and remained elevated for as long as 9 days postoperatively in comparison with isolated coronary artery bypass grafting, for which the risk returned to near baseline by postoperative day 6. Phase I and phase II periods are associated with distinct risk factors; therefore, it is likely that the mechanisms of postoperative atrial fibrillation change over time.

Moderate mitral regurgitation in aortic root replacement surgery: Comparing mitral repair with no mitral repair

Patients often present for aortic root replacement surgery with concomitant mitral valve pathology. Moderate mitral regurgitation is the point of clinical equipoise where the benefits of intervention compared with observation are currently unknown. This study compares outcomes in patients undergoing aortic root replacement surgery who did or did not receive a mitral valve repair for their preoperative moderate mitral regurgitation. A total of 1316 patients who underwent aortic root replacement surgery between 2000 and 2011 were evaluated, with 104 patients meeting the inclusion criteria by presenting with moderate preoperative mitral regurgitation. A total of 73 patients (70%) received no mitral intervention, and 31 patients (30%) received amitral repair. Patients underwent preoperative, postoperative, and greater than 6-month follow-up echocardiograms. Average clinical follow-up was 6.5 years. The mitral repair group had increased preoperative New York Heart Association III/IV and heart failure, longer crossclamp times, and more postoperative renal failure (P=.0003, P=.04, P<.0001, and P=.03, respectively). The improvement in mitral regurgitation was greater for the mitral repair group (-2.1± 0.3 vs -1.1 ± 0.8, P<.0001), and mitral regurgitation remained significantly lower on follow-up at 6 months or more (0.6 ± 0.4 0.9 ± 0.2, P=.002). A significantly greater percentage of patients undergoing mitral repair compared with patients with no repair had improvement of at least 1 grade in mitral regurgitation postoperatively (100% vs 70%, P=.001) and on follow-up at 6 months or more (90% vs 61%, P=.006). There was no difference in long-term survival, freedom from 2+ or greater mitral regurgitation, or mitral reinterventions. Mitral repair along with aortic root replacement has acceptable operative risk. Aortic root replacement surgery alone improved mitral regurgitation, but the addition of mitral repair further reduced mitral regurgitation, suggesting that repairing moderate mitral regurgitation should generally be considered along with aortic root replacement.

Pediatric RIFLE for Acute Kidney Injury Diagnosis and Prognosis for Children Undergoing Cardiac Surgery: A Single-Center Prospective Observational Study

This study evaluated the performance of the pediatric RIFLE (pRIFLE) score for acute kidney injury (AKI) diagnosis and prognosis after pediatric cardiac surgery. It was a single-center prospective observational study developed in a pediatric cardiac intensive care unit (pCICU) of a tertiary children's hospital. The study enrolled 160 consecutive children younger than 1 year with congenital heart diseases and undergoing cardiac surgery with cardiopulmonary bypass. Of the 160 children, 50 (31 %) were neonates, and 20 (12 %) had a univentricular heart. Palliative surgery was performed for 53 patients (33 %). A diagnosis of AKI was determined for 90 patients (56 %), and 68 (42 %) of these patients achieved an "R" level of AKI severity, 17 patients (10 %) an "I" level, and 5 patients (3 %) an "F" level. Longer cross-clamp times (p = 0.045), a higher inotropic score (p = 0.02), and a higher Risk-Adjusted Classification for Congenital Heart Surgery score (p = 0.048) but not age (p = 0.27) correlated significantly with pRIFLE class severity. Patients classified with a higher pRIFLE score required a greater number of mechanical ventilation days (p = 0.03) and a longer pCICU stay (p = 0.045). Renal replacement therapy (RRT) was needed for 13 patients (8.1 %), with two patients receiving continuous hemofiltration, and 11 patients receiving peritoneal dialysis. At the start of dialysis, the distribution of RRT patients differed significantly within pRIFLE classes (p = 0.015). All deceased patients were classified as pRIFLE "I" or "F" (p = 0.0001). The findings showed that pRIFLE is easily and feasibly applied for pediatric patients with congenital heart disease. The pRIFLE classification showed that AKI incidence in pediatric cardiac surgery infants is high and associated with poorer outcomes.