Low Operative Mortality Research Articles

Twenty Years of Adult Congenital Heart Surgery: A Single-Center African Experience.

Lack of data exists on the surgical management of adult congenital heart disease on the African continent. This study was undertaken to describe the clinical profile and surgical outcome of adult patients with congenital heart disease undergoing surgery in a single-center African study population. A retrospective medical chart review of consecutive adult patients (≥18 years) undergoing congenital heart surgery between October 1995 and December 2015 at our institution was undertaken. We described cardiac diagnosis, diagnostic complexity, risk profile, and surgical morbidity and mortality. Data were collected of 233 surgical procedures performed in 219 patients (45.6% males). The most common diagnostic category was septal defects (41.2%), followed by right heart lesions (17.2%), left heart lesions (12.4%), thoracic arteries (9.0%), and conduit failure (6.9%). Twenty-four percent of patients presented in functional class III or IV, and 46% of patients met the criteria for the simple Bethesda diagnostic class. Preoperative risk factors were identified in 19.8% of patients. Corrective surgery was performed in 71.7% of cases, reoperative surgery in 27.6%, and palliative surgery in 0.8%. Right ventricle to pulmonary artery conduit placement comprised 53.1% of reoperations. The overall hospital mortality was 1.7%. Postoperative complications occurred in 26.3% of cases. This study presents a detailed description of this emerging population in a developing world context. Our outcomes data suggest that adult congenital heart disease surgery is feasible in a Southern African tertiary referral center with low operative mortality and acceptable morbidity.

Left-to-Right Shunts

Contrary to the opinion of French pediatrician Henri-Louis1 that isolated ventricular septal defects (VSDs) are universally well tolerated, the subsequent discoveries of Eisenmenger,2 Abbott,3 Wood,4 and others have taught us that the prognosis of left-to-right shunt lesions is not always benign. After more than a century of research, as pediatric cardiologists and congenital heart surgeons, we claim that we know what happens in the lungs and the hearts of these patients and when these changes occur. The repair of VSDs has become routine since Lillehei’s, Warden’s, and Kirklin’s5,6 pioneering work in the 1950s, and we feel that we know in whom, at what age, and for which signs and symptoms to intervene. In reality, significant heterogeneity prevails between different centers and among individual physicians with regard to whether and when to close an isolated moderately restrictive VSD or patent arterial duct. Conceptually, we agree to occlude left-to-right shunts for one or both of the 2 reasons: to treat heart failure and to prevent irreversible pulmonary vascular damage, both of which have been identified as important risk factors in congenital heart disease. The study by Pereda et al7 from Madrid and Barcelona, published in this issue of Circulation: Cardiovascular Imaging , leads us to consider the fate of the myocardium as well. When counseling parents, we point out the low operative mortality and excellent long-term prognosis after successful VSD or patent arterial duct closure. Indeed, postoperative pulmonary hypertensive crises and more than transient and mild ventricular dysfunction are rare occurrences after shunt repair in infancy in the current era. Nonetheless, most of us vividly remember the stormy early postoperative course in the occasional …

Early Experience of Robot-Assisted Esophagectomy With Circular End-to-End Stapled Anastomosis

Surgical resection is a critical element in the treatment of esophageal cancer. Esophagectomy is technically challenging and is associated with high morbidity and mortality rates. Efforts to reduce these rates have spurred the adoption of minimally invasive techniques. This study describes a single-institution experience of robot-assisted esophagectomy with circular end-to-end stapled anastomosis. Between December 2013 and April 2015, a series of consecutive patients underwent robot-assisted Ivor Lewis esophagectomy with circular end-to-end anastomosis (RAILE-EEA) at a tertiary care center with curative intent. We retrospectively reviewed their electronic medical records using real-time prospectively collected data. The operative and postoperative outcomes were recorded. Twenty patients underwent RAILE-EEA during the study period. The abdominal mobilization was performed laparoscopically, and the thoracic portion was robotic. The median total operative time was 455 minutes (range, 318-765 minutes), the 90-day operative mortality was 0%, and morbidity was present in 11 of 20 patients (55%). Atrial fibrillation was the most common event and was observed in 3 patients (15%). There were no anastomotic leaks. The median estimated blood loss was 275 mL, and the conversion rate was 0%. Complete (R0) resection was achieved in all cases. The mean number of lymph nodes was 23.2 (± 2.26). The median follow-up time was 330 days (range, 108-600 days), and the overall 1-year survival was 84%. RAILE-EEA in our institution suggests a safe, effective, and reproducible alternative with satisfactory postoperative outcomes for the treatment of esophageal cancer. It provided good local control, adequate lymphadenectomy, low morbidity, and low 90-day operative mortality.

Comparison of Outcomes following Mitral Valve Repair versus Replacement for Chronic Ischemic Mitral Regurgitation: A Meta-Analysis.

Background The selection of mitral valve surgery, including mitral valve repair and mitral valve replacement, is still an important dilemma for patients with chronic ischemic mitral regurgitation. We carry out a meta-analysis to evaluate the effectiveness and safety of mitral valve repair versus replacement for ischemic mitral regurgitation. Methods We searched PubMed, Embase, the Cochrane Library, and Web of Science to identify studies from their inception to July 2015. A meta-analysis was performed using RevMan 5.3 software (Cochrane Collaboration, Oxford, United Kingdom). A random-effect model was used and sensitivity analysis was performed on studies reporting on operation after 2000, high-quality studies, and those studies reporting on more than 150 patients. Result A total of 2,324 patients were identified from 10 retrospective studies. Mitral valve repair was associated with a trend toward lower operative mortality (odds ratio [OR] = 0.45; 95% confidence interval [CI]: 0.31-0.65; p < 0.0001) and higher recurrence of mitral regurgitation (OR = 5.89; 95% CI: 3.34-10.39; p < 0.00001). Five-year survival rate was similar between the two groups (OR = 1.20; 95% CI: 0.88-1.65; p = 0.25). No differences in reoperation, the incidence of acute renal failure and acute respiratory failure, the length of ICU stay, and the length of hospital stay were found. Conclusion Mitral valve repair was associated with lower operative mortality but a higher recurrence of mitral regurgitation compared with mitral valve replacement. Owing to the limited quantity and quality of the included studies, this conclusion still needs to be further confirmed by conducting more high-quality, multicenter randomized controlled trials with large sample size.

2015 Young Surgeon’s Award Winner: Long-term Prognosis in Patients with Diabetes Mellitus after Coronary Artery Bypass Grafting: A Propensity-Matched Study

We aimed to determine the impact of diabetes mellitus (DM) on long-term survival after coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease. A retrospective review was conducted for 5720 consecutive patients who underwent isolated first CABG between 1982 and 1999. Outcomes were reviewed to include in-hospital mortality and long-term survival. Mean follow-up was 13.0 ± 5.8 years. To obtain comparable subgroups, 561 diabetic patients were matched with 561 non-diabetic controls based on estimated propensity scores. Mean age was 59.3 ± 9.1 years with 4373 (76.5%) males. Amongst 5720 patients, 1977 (34.6%) had DM. Hypertension and dyslipidaemia were the most common cardiovascular comorbidities, present in 2920 (51.0%) and 2664 patients (46.6%) respectively. Emergency surgery was performed in 563 patients (9.8%). In-patient mortality occurred in 115 patients (2.0%), 48 (2.4%) in the DM group and 67 (1.8%) in the non-DM group, (P = 0.102). In the unmatched cohort, overall 20-year survival rates were 30.9 ± 1.6% in diabetics and 49.2 ± 1.0% in non-diabetics (P <0.001). Freedom from cardiac mortality at 20 years was 56.0 ± 2.0% in diabetics and 68.4 ± 1.0% in non-diabetics (P <0.001). In the propensity-matched group, overall 20-year survival rates were 35.4 ± 2.5% in diabetics and 48.9 ± 2.9% in non-diabetics (P <0.001). Freedom from cardiac mortality at 20 years was 57.8 ± 3.0% in diabetics and 70.2 ± 2.9% in non-diabetics (P = 0.001). Multivariable Cox regression analysis identified age (hazard ratio (HR): 1.03/year), female gender (HR: 1.43), DM (HR: 1.51), previous myocardial infarction (HR: 1.54) and left ventricular ejection fraction (LVEF) <35% (HR: 2.60) as independent factors influencing long-term cardiac mortality. Despite low operative mortality, long-term survival and freedom from cardiac death are significantly lower in patients with DM compared to non-diabetics. Aggressive treatment of DM, cardiovascular comorbidities and smoking cessation are essential to improve long-term survival in diabetic patients.

Operative Outcomes with Myxomatous Mitral Valve Repair: Experience with 586 Patients

American Heart Association (AHA) guidelines recommend mitral valve repair for myxomatous mitral regurgitation whenever possible to prevent LV dysfunction and early mortality. Here we review our early operative outcomes with mitral valve repair for myxomatous mitral regurgitation. We collected data from 586 consecutive patients that underwent mitral repair for myxomatous disease at the Prince Henry and Prince of Wales Hospitals Sydney between 1997 and 2012. All patients had pre- and postoperative transthoracic echocardiograms. In the first 30 days postoperatively there were five deaths (0.9%), four strokes (0.7%) and five transient ischaemic attacks (TIAs) (0.9%). Repair involved resection in 55.5%, neochordal reconstruction in 41.6%, and in 2.9% a combination of both. There was increasing use of neochordae since 2006. At discharge 99% had mitral regurgitation (MR) ≤ mild and ≤ trivial in 79.5%. For posterior leaflet disease neochordae had improved MR at discharge compared with resection (85% vs 78%, P<0.05). Preoperative triscupid regurgitation (TR) and pulmonary hypertension > mild were associated with a greater degree of MR at discharge (P<0.05) for reasons that are unclear. We have shown excellent early results for mitral repair with very low operative mortality and excellent freedom from significant MR. Successful mitral repairs with low morbidity have resulted in a pattern of early referral in keeping with the current guidelines.

Surgical Outcomes and Predictors of Recurrence in Elderly Patients with Meningiomas

Meningiomas are more prevalent with increasing age, and there is no general consensus of surgical management for this group of tumors. The role of resection and the predictors of recurrence of meningiomas in elderly patients have not been well established. The authors reviewed their experience of surgical resection of these tumors in elderly patients and determined the factors for recurrence. Clinical and radiologic information of 81 elderly patients with meningiomas was retrospectively reviewed. Simpson grading scales were used to evaluate the extent of surgical resection. Statistical analysis was conducted using Kaplan-Meier curves and Cox proportional hazards regression. In this study, the recurrence rate in the grades I-II resection group was 10%, whereas in the grades III-IVresection group, the recurrence rate was 46% (P < 0.001). In Cox regression analysis, Simpson grades I-II/complete resection was revealed as a significant predictor of recurrence-free survival (P= 0.002). The hazard ratio for recurrence after grades III-IV resection was 5 times higher than after grades I-II resection. Location, size of the tumor, medical comorbidities, Karnofsky Performance Status,Geriatric Scoring System (GSS) score >16, and repeated resection were identified as predictors of recurrence-free survival after resection of meningiomas. Elderly patients with meningiomas having a GSS score >16 and undergoing Simpson grades I-II/gross total resection have low operative morbidity, mortality, and recurrence rates and are less likely to continue on antiepileptic medications. Although complete tumor resection is the goal, the surgical approach should be tailored to each patient depending on the patient's GSS score.

Fenestrated Endovascular Aortic Aneurysm Repair as a First Line Treatment Option to Treat Short Necked, Juxtarenal, and Suprarenal Aneurysms

The outcomes of fenestrated endovascular aneurysm repair (FEVAR) as a first line strategy is reported. All consecutive patients treated with FEVAR for short neck, juxtarenal, or suprarenal aortic aneurysms under the guidance of the senior author within the period January 2010 to December 2014 were included. Data were collected from a prospectively maintained database. Analyzed outcomes included technical success, defined by successful stent graft implantation with patent stented target vessels and no Type I/III endoleak, operative mortality and morbidity, target vessel patency, endoleak, re-intervention, and death. Survival, target vessel stent patency, and re-intervention during follow up were calculated by Kaplan-Meier analysis. A total of 281 patients (245 male, mean age 72.1±7.7 years) were treated. The mean aneurysm diameter was 60.2±9.3mm and median proximal neck length 2mm (range 0-10mm). Technical success was 96.8% (272/281). Technical failure included one intra-operative death due to embolization and cardiac arrest, one open conversion due to iliac rupture, and seven target vessel complications. The thirty day mortality was 0.7% (2/281). Mean follow up was 21±15.9 months. Estimated survival at 1 and 3 years was 94.7%±1.6% and 84.6%±3.0%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 96.1%±1.4%, and 90%±2.7%. Estimated target vessel stent patency at 1 and 3 years was 98.6%±0.5%, and 98.1%±0.6%, respectively. Mean aneurysm sac diameter decreased from 60.2±9.3mm pre-operatively to 53.2±12.8mm (p<.001). FEVAR as a first line strategy was associated with high technical success and a low operative mortality rate. Efficacy and durability in the mid-term appear very good, with significant regression of aneurysm sac diameter, high target vessel patency, and acceptable rate of re-intervention.

Short- and long-term outcomes of pneumonectomy in a tertiary center.

Surgery is the most important therapeutic modality for lung cancer. Surgical outcomes are normally reported as 30-day or 90-day mortality or 5-year survival; 10-year survival is rarely mentioned in national data or international studies. Three hundred and six patients (79% male) underwent pneumonectomy, mainly for lung cancer, from January 1998 to February 2013. Their short- and long-term outcomes up to September 2014 were analyzed retrospectively. The mean age was 64 years (range 22-82 years) and 24% were aged ≥70 years. Thoracoscore was used to calculate the risk of hospital mortality. Operative mortality was 4.5% whereas predicted mortality was 8%. The operative mortality for cancer patients was 3.3%; the national mortality for lung cancer is 6.5%. Only 2 patients died in hospital after a pneumonectomy in the last 5 years. Half of the patients who died in hospital were ≥70 years old; 29% (4 patients) died after urgent operations for nonmalignant disease. Overall 5- and 10-year survival was 32% and 20%. Median and mean survival was 26 and 57 months, respectively. Long-term survival was better in females aged <70 years, in left pneumonectomy patients, and in those with squamous cell lung cancer. Our mortality for pneumonectomy was 50% less than the national mortality rate and significantly lower than that predicted by the Thoracoscore for lung cancer. This confirms that pneumonectomy is still an effective modality for the treatment of lung cancer, with low operative mortality and good long-term survival, especially in younger patients.

Extended myectomy in the treatment of patients with hypertrophic obstructive cardiomyopathy.

IntroductionPartial resection of the septal muscle is a well-established and effective method of surgical treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM). The procedure is characterized by a low operative mortality rate and long-term clinical improvement that has been confirmed in numerous publications. Mitral insufficiency in patients with HOCM is mostly functional due to the effect of systolic anterior motion (SAM).AimTo present the early results of surgical treatment provided to HOCM patients and to compare the effectiveness of two surgical procedures: isolated myectomy and myectomy combined with mitral valve replacement.Material and methodsThe study analyzed a group of 49 patients (20 women) with HOCM who underwent surgical treatment between 2012 and 2015. Isolated myectomy was performed in 67.25% (n = 33) of patients, myectomy combined with mitral valve replacement in 30.61% (n = 15), and 1 (2.04%) patient underwent myectomy combined with mitral valvuloplasty (papillary muscle repositioning).ResultsA greater reduction of the left ventricular outflow tract (LVOT) gradient was observed in the population with concomitant mitral valve replacement in comparison to patients after isolated myectomy; the difference was statistically significant (p = 0.020). No significant correlation was observed between residual SAM and the grade of mitral regurgitation (p = 0.699) or between residual SAM and the LVOT gradient (p = 0.280).ConclusionsSurgical myectomy is a well-established, effective method of reducing increased LVOT gradients in patients with HOCM. Additional mitral valve replacement may be associated with greater reductions of the LVOT gradient in the early postoperative period. Valve replacement should be considered in patients with concomitant mitral valve degeneration and patients with narrowed left ventricular cavities.

Abstract 13977: Low Operative Mortality Achieved With Surgical Septal Myectomy: Role of Dedicated Hypertrophic Cardiomyopathy Centers in the Management of Dynamic Subaortic Obstruction

Background: Treatment of progressive heart failure, due to left ventricular (LV) outflow tract obstruction has been a major component of hypertrophic cardiomyopathy (HCM) disease management for 50 years. Septal myectomy has been the primary treatment option to abolish gradients and relieve heart failure symptoms. The role of myectomy in HCM management has depended on effectiveness in relieving heart failure symptoms, but also an acceptable operative risk. Methods: Over the most recent 15-year period, we reviewed 3,700 consecutive isolated myectomy operations performed at major North American HCM institutions. Composite operative mortality (first 30 days) was only 0.4%. Seventeen operative deaths were at ages 24 to 82 (≥70 years), and only 6 occurred after 2010. Notably, 2 of the 4 Mayo Clinic deaths were in patients with prior alcohol septal ablation. Septal myectomy, when performed in experienced HCM centers, was much safer when compared to operative mortality with coronary artery bypass grafting (2.3%); valve replacement (3.5%); mitral valve replacement specifically (5.7%) (STS Database), similar to atrial or ventricular septal defect closure and 15-fold less than myectomy in community hospital or low volume surgical settings. Conclusions: Surgical myectomy performed in dedicated HCM centers with experienced surgeons and staff is one of the safest open-heart procedures currently practiced, with a mortality rate as low as 0.4%. The large mortality discrepancy for myectomy between community hospitals and dedicated HCM centers underscores that this operation should be considered a specialized procedure best performed in high volume HCM institutions.

Comparison of Transanal Endoscopic Microsurgery and Total Mesorectal Excision in the Treatment of T1 Rectal Cancer: A Meta-Analysis.

BackgroundTransanal endoscopic microsurgery (TEM) for the treatment of early-stage rectal cancer has attracted attention due to its advantages of reduced surgical trauma, fewer complications, low operative mortality, rapid postoperative recovery and short hospital stay. However, there are still significant controversies regarding TEM for the treatment of rectal cancer, mainly related to the prognosis associated with this method.ObjectiveThis study sought to compare the efficacy of transanal endoscopic microsurgery (TEM) and total mesorectal excision (TME) for the treatment of T1 rectal cancer.MethodsWe searched the Cochrane Library, PubMed, Embase and CNKI databases. Based on the Cochrane Handbook for Systematic Reviews, we screened the trials, evaluated the quality and extracted the data.ResultsOne randomized controlled trial (RCT) and six non-randomized controlled clinical trials (CCTs) were included in the meta-analysis (a total of 860 rectal cancer patients were included; 303 patients were treated with TEM, and 557 patients were treated with TME). Analysis revealed that all seven studies reported local recurrence rates, and there was a significant difference between the TEM and TME groups [odds ratio (OR) = 4.62, 95% confidence interval (CI) (2.03, 10.53), P = 0.0003]. A total of five studies reported distant metastasis rates, and there was no significant difference between the TEM and TME groups [OR = 0.74, 95%CI (0.32, 1.72), P = 0.49]. A total of six studies reported postoperative overall survival of the patients, and there was no significant difference between the TEM and TME groups [OR = 0.87, 95%CI(0.55, 1.38), P = 0.55]. In addition, two studies reported the postoperative disease-free survival rates of patients, and there was no significant difference between the TEM and TME groups [OR = 1.12, 95%CI (0.31, 4.12), P = 0.86].ConclusionsFor patients with T1 rectal cancer, the distant metastasis, overall survival and disease-free survival rates did not differ between the TEM and TME groups, although the local recurrence rate after TEM was higher than that after TME.

Clinical feasibility and efficacy of video-assisted thoracic surgery (VATS) anatomical resection in patients with central lung cancer: a comparison with thoracotomy.

The aim of this study is to evaluate the clinical feasibility and efficacy of video-assisted thoracoscopic surgery (VATS) anatomical pulmonary resection in patients with central lung cancer. Between July 2004 and December 2011, 465 patients underwent anatomical pulmonary resection and systematic mediastinal lymph node sampling or dissection for central lung cancer. Because patients were not randomized to receive VATS, clinical outcomes were compared using a propensity score matching design, giving 88 patients in each group. A lobectomy was attempted in 69 patients of the thoracotomy group and 64 of the VATS group, bilobectomy in 19 patients of the thoracotomy group and 21 of the VATS group, and segmentectomy in 3 patients of the VATS group. There were no differences in the anatomical distribution of pulmonary resections between the two groups. There was no operation related in-hospital mortality. There were 34 postoperative complications in 30 patients, without significant differences between the two groups. The median hospital stay and chest tube indwelling period of the VATS group were shorter than those of the thoracotomy group by 2 days and 1 day, respectively (P<0.05). During a median follow-up of 32.5 months (range, 0.5-95.8 months), there was no difference between the two groups in 3-year recurrence-free or overall survivals (OS). VATS anatomical pulmonary resection is safe and feasible for central lung cancer, providing a low operative mortality and favorable outcomes in selected patients. Further case studies with long-term outcome data are necessary to verify our conclusions.

Pulmonary Thromboendarterectomy Experience at the Cleveland Clinic

SESSION TITLE: Pulmonary Arterial Hypertension Posters II SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: Pulmonary hypertension due to unresolved pulmonary emboli that narrow pulmonary arteries, known as chronic thromboembolic pulmonary hypertension (CTEPH), is a deadly disease that can be effectively treated with a complex surgical procedure called pulmonary thromboendarterectomy (PTE). The Cleveland Clinic has a multidisciplinary team dedicated to the evaluation and treatment of CTEPH patients. Here, we report our PTE experience. METHODS: Retrospective review of all patients who underwent PTE at the Cleveland Clinic. We report surgical volumes and hospital mortality. For recent cohorts, we report detailed demographic, clinical and hemodynamic data before and after PTE, as well as long term survival. RESULTS: Between 1995 and 2014, a total of 150 PTE surgeries were performed at the Cleveland Clinic. Between 1995 and 2010, there were a total of 86 PTEs with a hospital mortality rate of 11.6%. Between 2011 and 2014, we performed 64 PTE surgeries with a hospital mortality rate of 4.7%. Patients operated between 2011 and 2014 had the following baseline characteristics: median age 51 (range 21-81); 61% male; NYHA functional class II 18%, III 64% and IV 18%; median body mass index 31 (range 22 - 54); median six-minute walk distance 291 meters (interquartile range [IQR] 221, 384), median NT-proBNP 764 pg/mL (interquartile range 180, 2132). Pre and post PTE invasive hemodynamics were as follows: mean PAP 45 (IQR 39, 55) and 25 (IQR 22, 31) mmHg, cardiac index 2.2 (IQR 1.8, 2.6) and 2.9 (IQR 2.6, 3.3) L/min/m2, pulmonary vascular resistance 6.2 (IQR 4.9, 10.1) and 2.4 (IQR 1.8, 3.1) Wood units, respectively. For 70 CTEPH patients treated with PTE between 2009 and 2014, 5 -year survival was 87.4%, compared to 63.3% for 31 contemporary CTEPH patients treated medically (log-rank p = 0.04). CONCLUSIONS: PTE is the treatment of choice for CTEPH as it is associated with low operative mortality; dramatic improvements right heart hemodynamics and excellent long-term outcomes, even in patients with severe disease and co-morbidities such as obesity. CLINICAL IMPLICATIONS: There is a need for emerging centers with a dedicated team of specialists to effectively evaluate and treat patients with CTEPH. DISCLOSURE: Gustavo Heresi: Consultant fee, speaker bureau, advisory committee, etc.: Bayer Healthcare The following authors have nothing to disclose: Nicholas Smedira No Product/Research Disclosure Information

Mechanisms of Mitral Valve Dysfunction Following Mitral Valve Repair for Degenerative Disease

Mitral valve repair is the treatment of choice for mitral regurgitation secondary to myxomatous degenerative valve disease given the associated low operative mortality and excellent long-term survival. Recurrent mitral valve dysfunction requiring reoperation following primary valve repair is

80. Atrioventricular septal defect and tetralogy of Fallot: A 16-year experience

Aim The choice between primary and staged repair of atrioventricular septal defect with tetralogy of Fallot (AVSD/TOF) is still controversial. We report our surgical experience with this lesion. Methods Twenty-four patients with AVSD/TOF were repaired between 1997 and 2013. Ten, group 1 (40%), underwent primary repair at a mean age of 29.4 months. Fourteen, group 2 (60%), underwent staged repair at a mean-age of 65.2 months. Mean interval between shunt and repair was 26.5 months. Out of 24 patients, 8 (33%) were repaired by transannular patch, 15 (62%) by pulmonary valve preservation and 1 by pulmonary valve replacement. Results There was one hospital death in group 2. Mean follow-up period was 70 months. In group 1 , 8 patients were alive while 2 were lost to follow-up. Three were re-operated, one for mitral valve repair and left diaphragmatic plication, one for thoracic duct ligation and one for pulmonary valve replacement. In group 2 , 10 patients were alive while 3 were lost to follow-up. One developed biventricular outflow obstruction and is awaiting surgery. One had ventricular septal defect device closure. There were 3 reoperations, one for left atrioventricular valve and pulmonary valve replacement, one for pulmonary valve replacement alone and one for relief of biventricular outflow obstruction. All transannular patch patients had dilated right ventricle with moderate to severe tricuspid valve regurgitation. Conclusion Shunt procedure is a reasonable initial option for many of patients with AVSD/TOF but primary repair can be performed in selected patients with low operative mortality and reasonable morbidity.

Preoperative characteristics and surgical outcomes of acute intramural hematoma involving the ascending aorta: A propensity score–matched analysis

ObjectiveWe aimed to evaluate the preoperative characteristics and surgical outcomes of acute type A intramural hematoma. MethodsBetween January 2000 and June 2011, 460 consecutive patients underwent emergency open surgery for type A acute aortic syndrome at Sakakibara Heart Institute. Among these patients, 121 had intramural hematoma and 339 had typical aortic dissection. We compared the clinical characteristics and surgical outcomes using propensity score matching. ResultsIn all patients, the intramural hematoma group had an older age (69.2 ± 10.4 years vs 63.4 ± 13.5 years; P < .001), included a higher ratio of female patients (56.2% vs 44.0%, P = .020), and more frequently had hypertension (94.2% vs 83.5%, P = .005), hyperlipidemia (25.6% vs 12.7%, P < .001), and cardiac tamponade (33.1% vs 18.3%, P < .001) than patients with aortic dissection. Cerebral malperfusion (0.8% vs 5.3%, P = .033), myocardial malperfusion (0.8% vs 8.2%, P = .002), lower limb malperfusion (1.7% vs 7.9%, P = .015), Marfan syndrome (0% vs 3.5%, P = .042), and aortic valve insufficiency (2.5% vs 15.0%, P < .001) were less frequently observed in the intramural hematoma group than in the aortic dissection group. After propensity score matching, 116 matched pairs were created. In the matched analysis, operative mortality was 0.9% in the intramural hematoma group (1/116) and 3.4% in the aortic dissection group (4/116, P = .179). The intramural hematoma group demonstrated higher actuarial 1- and 5-year survivals than the aortic dissection group (99.1 % vs 93.6% and 97.3% vs 85.9%, respectively, P = .006). In the multivariate analysis, intramural hematoma was shown to be associated with lower midterm mortality (hazard ratio, 0.316; 95% confidence interval, 0.102-0.974; P = .045). ConclusionsPatients with intramural hematoma have different preoperative clinical characteristics compared with patients with aortic dissection. Emergency open surgery for type A intramural hematoma demonstrated low operative mortality and excellent 5-year survival.

Ten year experience of using a novel metabolic protocol in 'off pump' coronary artery bypass revascularization.

Assessment of both short- and long-term outcomes in patients undergoing off-pump coronary artery bypass using a perioperative metabolic protocol. A total of 975 of 995 adult patients underwent coronary artery bypass 'off-pump' from 1997 through 2006. Patients presenting in cardiogenic shock were excluded from this assessment. A perioperative metabolic protocol, which included the implementation of allopurinol, insulin supplementation, magnesium sulfate, supplemental corticosteroids, milrinone, norepinephrine (prn), aspirin, clopidogrel, statins and β-blockers, was used in these patients. The mean age at the time of surgery was 70.5 years and the average number of bypass grafts was 4 per procedure; 18% (n = 176) of the cases had a preoperative intra-aortic balloon pump inserted for hemodynamic instability, tight left main coronary artery stenosis or angina. The 30-day mortality was 1.8% versus a Society of Thoracic Surgeons (STS) predicted mortality of 4.8%. Left main coronary artery disease was present in 38% (n = 371) of the patients. No strokes occurred intra-operatively and the postoperative incidence of stroke was 0.9% (n = 9). Incidence of renal failure requiring dialysis was 0.8% (n = 8). There was a single sternal infection. Mean follow up was 65 months with a survival rate of 90% (n = 955). Re-intervention, which commonly involved PTCA ± stent placement or re-do coronary artery bypass grafting (CABG), was 4% at 1 year and 11.6% (n = 113) during the 65-month follow-up period. Off-pump coronary artery bypass coupled with this novel metabolic protocol was associated with a low operative mortality and acceptable perioperative morbidities, including patients with left main coronary artery disease. These benefits are apparent at both short- and medium-term follow up.

Invited Commentary

Yazdchi and colleagues [1Yazdchi F. Koch C.G. Mihaljevic T. et al.Increasing disadvantage of “watchful waiting” for repairing degenerative mitral valve disease.Ann Thorac Surg. 2015; 99: 1992-2000Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] have contributed a 26-year experience describing trends in patient characteristics, surgical approaches, and outcomes in patients with degenerative mitral valve regurgitation. The news is encouraging. The authors document an important shift toward referral for mitral valve operation earlier in the disease process, before the adverse consequences of mitral regurgitation on the heart and pulmonary vasculature compromise long-term outcomes. Patients undergoing mitral valve operations for degenerative disease in this experience have progressively smaller ventricular and atrial dimensions, less manifest heart failure, a lower incidence of atrial fibrillation, and a higher likelihood of presenting without symptoms. The extremely low mortality and high rates of repair are a tribute to the entire perioperative care team, and these outcomes undoubtedly have shifted the equation toward earlier referral. The author’s institution is ahead of the national curve, where fewer than 10% (compared with 44% in this report) of referred patients are asymptomatic (The Society of Thoracic Surgeons Adult Cardiac Surgery Database, accessed October 2013). The repair rate of 93% exceeds the national average of 85% and is a reminder that highly reliable and durable mitral repair is probably best achieved by surgeons with a dedicated subspecialization in mitral valve repair. Key unanswered questions include the worth of “minimally invasive” mitral valve operations, which seem to be driving substantially increased cardiopulmonary and cross-clamp times. The next steps in the therapy of degenerative mitral valve disease include continued earlier referral for operation, truly less invasive (non-cardiopulmonary bypass and catheter-based) interventions, and simplification of repair strategies to increase mitral valve repair rates and enhance durability of repair. We are looking forward to the next era. Increasing Disadvantage of “Watchful Waiting” for Repairing Degenerative Mitral Valve DiseaseThe Annals of Thoracic SurgeryVol. 99Issue 6PreviewSuccessful durable repair of severe degenerative mitral regurgitation with low operative mortality encourages intervention in asymptomatic patients rather than “watchful waiting.” Our objectives were to assess trends in patient characteristics, timing of intervention, and evolving surgical techniques at a high-volume center, and determine effects of these changes on outcomes after mitral valve (MV) repair over a 25-year period. Full-Text PDF

Increasing Disadvantage of “Watchful Waiting” for Repairing Degenerative Mitral Valve Disease

Successful durable repair of severe degenerative mitral regurgitation with low operative mortality encourages intervention in asymptomatic patients rather than "watchful waiting." Our objectives were to assess trends in patient characteristics, timing of intervention, and evolving surgical techniques at a high-volume center, and determine effects of these changes on outcomes after mitral valve (MV) repair over a 25-year period. From January 1, 1985, to January 1, 2011, 5,902 patients underwent isolated repair (with or without tricuspid repair for functional regurgitation) for degenerative MV disease at Cleveland Clinic. For illustration, the experience is presented in 3 eras: 1985 to 1997 (era 1, n= 1,184), 1997 to 2005 (era 2, n= 2,400), and 2005 to 2011 (era 3, n= 2,318). In era 3, more patients were asymptomatic onpresentation (44% in New York Heart Association [NYHA] class I vs 25% in era 1), with less heart failure (11% vs 29%) and atrial fibrillation (9.9% vs 23%). Full sternotomy decreased from era 1 (n= 1,100/93%) to era 2 (n= 602/25%) (era 3, n= 717/31%), and robotic surgery emerged (n= 577/25%) in era 3. Median length of stay shortened (era 1= 7 days, era 2= 5.9 days, era 3= 5.2 days, p < 0.0001), and in-hospital mortality remained low (era 1= 5/0.42%, era 2= 5/0.21%, era 3= 1/0.043%); 0.73% overall required reoperation on the repaired valve before discharge, and 97% had 0 to 1+ regurgitation at discharge. Treatment trends over 25 years reveal that rather than watchful waiting, a more aggressive approach to degenerative MV disease, with earlier intervention for severe regurgitation in asymptomatic patients and less invasive operative techniques, is successful, safe, and effective.