Multivalve Surgery Research Articles

Hospital and surgeon surgical valvar volume and survival after multivalve cardiac surgery in Medicare beneficiaries

ObjectiveLong-term outcomes after multivalve cardiac surgery remain underevaluated. MethodsMedicare administrative claims from 2008 to 2019 identified beneficiaries undergoing multivalve surgery. Operative characteristics were doubly adjudicated using International Classification of Diseases and Current Procedural Technology codes. A multivariable flexible parametric model evaluated predictors of survival; regression standardization was performed to predict standardized survival probabilities (SSPs) at varying percentiles of annual valvar volume. ResultsOf 476,092 cardiac surgeries involving the aortic (AVS), mitral (MVS), or tricuspid (TVS) valve, 63,083 (13.3%) were identified as involving multi-valve surgery, including 22,884 MVS/TVS, 30,697 AVS/MVS, 3443 AVS/TVS, and 6059 AVS/MVS/TVS. Surgery occurred at 1157 hospitals by 2922 surgeons. Annual valvar volume (total AVS/MVS/TVS) was tallied for surgeons and hospitals. Median survival varied substantially by type of multivalve surgery: 8.09 (95% CI: 7.90-8.24) years in MVS/TVS, 6.65 (95% CI: 6.49-6.81) years in AVS/MVS, 5.77 (95% CI: 5.37-6.13) years in AVS/TVS, and 6.02 (95% CI: 5.64-6.38) years in AVS/MVS/TVS. SSPs were calculated across combined hospital/surgeon volume percentiles; the median SSP increased with increasing percentile of combined hospital/surgeon volume: 5th percentile, 5.77 (95% CI: 5.58-5.98), 25th percentile, 6.18 (95% CI: 6.07-6.28), 50th percentile, 6.56 (95% CI: 6.44-6.68), 75%th percentile, 6.86 (95% CI: 6.75-6.97), and 95th percentile, 7.58 (95% CI: 7.34-7.83) years, respectively. ConclusionsSurvival varied significantly by type of multivalve surgery, worsened with addition of concomitant interventions and improved substantially with increasing annual hospital and surgeon volume. Hospital volume was associated with an improved early hazard for death that abated beyond 3 months post surgery, while surgeon volume was associated with an improved hazard for death that persisted even beyond the first postoperative year. Consideration should be given to referring multivalve cases to high-volume hospitals and surgeons.

Long-Term Safety and Efficacy of Intraoperative Leadless Pacemaker Implantation During Valve Surgery

BackgroundIntraoperative implantation of leadless cardiac pacemakers (LCPs) under direct visualization during cardiac surgery is a novel strategy to provide pacing to patients with an elevated risk of postoperative conduction disorders or with a preexisting pacing indication undergoing valve surgery. ObjectivesThis study sought to evaluate the long-term safety and efficacy of intraoperative LCP implantation in 100 consecutive patients. MethodsRetrospective single-center cohort study of consecutive patients (n = 100) who underwent intraoperative LCP implantation during valve surgery. Safety and efficacy were assessed at implantation and follow-up visits. ResultsA total of 100 patients (age 68 ± 13 years, 47% female) underwent intraoperative LCP implantation. The surgery involved the tricuspid valve in 99 patients (99%), including tricuspid valve repair in 59 (59%) and tricuspid valve replacement in 40 (40%). Most of the patients (78%) underwent multivalve surgery. The indication for LCP implantation was elevated risk of postoperative atrioventricular block in 54% and preexisting bradyarrhythmias in 46%. LCP implantation was successful in all patients. During a median of 10.6 months (IQR: 2.0-22.7 months) of follow-up, no device-related complications occurred. At 12-month follow-up, the pacing thresholds were acceptable (≤2.0 V at 0.24 milliseconds) in 95% of patients. ConclusionsIntraoperative LCP implantation under direct visualization is a safe strategy to provide permanent pacing in patients undergoing valve surgery, with a postoperative electrical performance comparable to percutaneously placed LCPs.

Clinical Outcomes after Multivalve Surgery in Octogenarians: Evaluating the Need for a Paradigm Shift

Clinical Outcomes after Multivalve Surgery in Octogenarians: Evaluating the Need for a Paradigm Shift

What Determines Outcomes in Multivalve Reoperations? Effect of Patient and Surgical Complexity

Patient characteristics, risks, and outcomes associated with reoperative multivalve cardiac surgery are poorly characterized. Effect of patient variables and surgical components of each reoperation were evaluated with regard to operative mortality. From January 2008 to January 2022, 2324 patients with previous cardiac surgery underwent 2352 reoperations involving repair or replacement of multiple cardiac valves at Cleveland Clinic. Mean age was 66±14years. Number of surgical components representing surgical complexity (valve procedures, aortic surgery, coronary artery bypass grafting, and atrial fibrillation procedures) ranged from 2 to 6. Random forest for imbalanced data was used to identify risk factors for operative mortality. Surgery was elective in 1327 (56%), urgent in 1006 (43%), and emergency in 19 (0.8%). First-time reoperations were performed in 1796 (76%) and 556 (24%) had 2 or more previous operations. Isolated multivalve operations comprised 54% (1265) of cases; 1087 incorporated additional surgical components. Two valves were operated on in 80% (1889) of cases, 3 in 20% (461), and 4 in 0.09% (2). Operative mortality was 4.2% (98 out of 2352), with 1.7% (12 out of 704) for elective, isolated multivalve reoperations. For each added surgical component, operative mortality incrementally increased, from 2.4% for 2 components (24 out of 1009) to 17% for ≥5 (5 out of 30). Predictors of operative mortality included coronary artery bypass grafting, surgical urgency, cardiac, renal dysfunction, peripheral artery disease, New York Heart Association functional class, and anemia. Elective, isolated reoperative multivalve surgery can be performed with low mortality. Surgical complexity coupled with key physiologic factors can be used to inform surgical risk and decision making.

Early Neurological Complications after Cardiac/Aortic Surgery with Cardiopulmonary Bypass: Incidence and Risk Factors

Objective: To examine the incidence and risk factors of early neurological complications after cardiac or aortic surgery using cardiopulmonary bypass technique in King Chulalongkorn Memorial Hospital, Thailand. Materials and Methods: The present study was a retrospective cohort study. Clinical data of adult patients that underwent cardiac or aortic surgery using cardiopulmonary bypass technique in 2018 were reviewed from the electronic medical record in the authors’ center. Results: Early postoperative neurological complications occurred in 33 (8.3%) of the 400 patients. Twenty of them (60.6%) had non-specific encephalopathy, three (9.1%) had hypoxic-ischemic encephalopathy, five (15.2%) had provoked seizure, four (12.1%) had cerebral infarction, and one (3.0%) had intracranial hemorrhage. Associated clinical factors included history of essential hypertension [adjusted odds ratio 3.448 (95% CI 1.266 to 9.391)], combined coronary artery bypass grafting and valve surgery [adjusted odds ratio 4.759 (95% CI 1.182 to 19.170)], multi-valve surgery [adjusted odds ratio 5.201 (95% CI 1.227 to 22.049)], aortic surgery [adjusted odds ratio 17.260 (95% CI 4.168 to 71.468)], higher midazolam dosage [adjusted odds ratio 1.009 (95% CI 1.002 to 1.015)], higher serum lactate prior to discontinuing cardiopulmonary bypass [adjusted odds ratio 1.263 (95% CI 1.093 to 1.460)], and presence of intraoperative intra-aortic balloon pump use [adjusted odds ratio 6.160 (95% CI 1.883 to 20.150)]. Conclusion: Early postoperative neurological complications rate of cardiac or aortic surgery using cardiopulmonary bypass technique in the present study settings was 8.3%. Preoperative and intraoperative clinical factors associated with such complications were the history of essential hypertension, the type of surgery such as combined coronary artery bypass grafting and valve surgery, multi-valve surgery, and aortic surgery, the higher midazolam dosage, the higher serum lactate prior to discontinuing cardiopulmonary bypass, and the presence of intraoperative intra-aortic balloon pump use. Keywords: Cardiac surgery; Aortic surgery; Cardiopulmonary bypass; Postoperative neurological complications; Encephalopath

Evaluation of postoperative outcomes of valve reoperation: a retrospective study.

The aim of this study was to compare the incidence of operative death and postoperative complications between primary and reoperation valve surgeries and to identify independent risk factors for these events among valve-reoperation patients. Between 2013 and 2015, 54269 patients who underwent valve surgery were retrospectively analyzed using the Japan Cardiovascular Surgery Database. They were divided into the primary (group P; n = 49833) and reoperation (group R; n = 4436) surgery groups. Among the reoperation patients, we conducted multivariable logistic regression analyses to identify risk factors for the incidences of operative mortality and postoperative complications. Then, we also conducted propensity score matched analyses to compare the incidences of these 2 outcomes for primary versus reoperation procedures separately for patients with and without infective endocarditis (IE). Incidences of postoperative mortality (4.6% vs 9.1%; P < 0.001) and any complications (36.6% vs 41.4%; P < 0.001) were higher in the reoperation group. For patients undergoing reoperation, strong risk factors for operative mortality included urgency status, ejection fraction <30%, IE, dialysis, chronic kidney disease, New York Heart Association class 3/4, concomitant coronary artery bypass grafting and aorta procedure, tricuspid valve surgery only, multivalve surgery and age. In the propensity score matched cohort, the relative odds of operative mortality were 1.53 (95% confidence interval: 1.26-1.86, P < 0.001) among patients with IE and were 1.58 (95% confidence interval: 1.18-2.13, P < 0.002) among those without. Outcomes for reoperation were significantly worse than those for primary surgery. At the primary operation, the risk of reoperation should be considered and when considering the indications for reoperation, the preoperative state, surgical timing and intervention method should be considered.

Leadless pacemaker implantation under direct visualization during valve surgery

ObjectiveThe leadless cardiac pacemaker is typically implanted percutaneously and has been widely used for patients who have already undergone valve surgery. We sought to determine the feasibility and safety of implanting the leadless pacemaker under direct visualization during valve surgery. MethodsWe performed a retrospective analysis of consecutive adult patients (n = 15) who underwent implantation of a leadless pacemaker under direct visualization at the time of valve surgery. Indications for single-chamber pacing were sick sinus syndrome with pauses (53.3%), atrial fibrillation with slow ventricular rates (13.3%) or complete heart block (6.6%), and elevated risk for postoperative heart block (26.6%). Leadless pacemaker performance and pacing percentage were assessed. ResultsPatients' age was 67.5 ± 17 years, 6 patients (40%) were male, and 14 patients (93%) had atrial fibrillation. Isolated tricuspid valve replacement was performed in 5 patients (33.3%), and the remainder underwent multivalve surgery that included concomitant tricuspid valve repair/replacement. In 93% of the patients (n = 14), the immediate post–cardiopulmonary bypass pacing thresholds were normal (≤2.0 V at 0.24 ms) and normalized in the remaining patient by the next morning. The impedance/sensing values were normal and stable through follow-up (151 ± 119 days) in all patients. Reliable leadless pacemaker performance allowed for deferral of temporary epicardial wires in 11 patients (73%). There were no procedural complications or device malfunction. ConclusionsLeadless cardiac pacemaker implantation during valve surgery is feasible and safe. This hybrid approach to pacing may simplify the perioperative management of patients undergoing valve surgery who have an indication for single-chamber pacing.

Combined Valve Operations in the Aortic and Mitral Positions With or Without Added Tricuspid Valve Repair

There is limited clinical evidence on when to address tricuspid regurgitation in patients with aortic and mitral valve disease requiring surgical intervention. In this study, we aimed to investigate the potential added value of performing a tricuspid valve repair concomitantly in patients requiring double valve surgery (DVS) of the aortic and mitral valves. We reviewed 223 cases of multivalve surgery from 2011 to 2016. In this single-institution series, 190 underwent DVS in aortic and mitral positions and 33 had triple valve surgery in aortic, mitral, and tricuspid positions. Preoperative and postoperative echocardiograms were evaluated to determine changes in valve function. A logistic regression model was performed to assess relationship of patient comorbidities and type of valve operations to perioperative adverse events. Mid-term survival was similar between the 2 groups (P = 0.541). Compared to DVS, TVS was not associated with an increased risk of perioperative adverse events, including need for pacemaker or mortality on multivariable analysis. Within the DVS subgroup, 19.8% of patients experienced improvement in tricuspid valve function with decrease in the degree of tricuspid regurgitation within a 6-month postoperative follow-up. Our study indicates that repairing the tricuspid valve while addressing the aortic and mitral valves does not pose significant additional risk. The observed improvement of the degree of tricuspid regurgitation without tricuspid operation suggests the need to further define subpopulations of patients with multivalvular disease.

Pacemaker Implantation After Mitral Valve Surgery With Atrial Fibrillation Ablation

BackgroundThe incidence of permanent pacemaker (PPM) implantation is higher following mitral valve surgery (MVS) with ablation for atrial fibrillation (AF) compared with MVS alone. ObjectivesThis study identified risk factors and outcomes associated with PPM implantation in a randomized trial that evaluated ablation for AF in patients who underwent MVS. MethodsA total of 243 patients with AF and without previous PPM placement were randomly assigned to MVS alone (n = 117) or MVS + ablation (n = 126). Patients in the ablation group were further randomized to pulmonary vein isolation (PVI) (n = 62) or the biatrial maze procedure (n = 64). Using competing risk models, this study examined the association among PPM and baseline and operative risk factors, and the effect of PPM on time to discharge, readmissions, and 1-year mortality. ResultsThirty-five patients received a PPM within the first year (14.4%), 29 (83%) underwent implantation during the index hospitalization. The frequency of PPM implantation was 7.7% in patients randomized to MVS alone, 16.1% in MVS + PVI, and 25% in MVS + biatrial maze. The indications for PPM were similar among patients who underwent MVS with and without ablation. Ablation, multivalve surgery, and New York Heart Association functional (NYHA) functional class III/IV were independent risk factors for PPM implantation. Length of stay post-surgery was longer in patients who received PPMs, but it was not significant when adjusted for randomization assignment (MVS vs. ablation) and age (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.61 to 1.08; p = 0.14). PPM implantation did not increase 30-day readmission rate (HR: 1.43; 95% CI: 0.50 to 4.05; p = 0.50). The need for PPM was associated with a higher risk of 1-year mortality (HR: 3.21; 95% CI: 1.01 to 10.17; p = 0.05) after adjustment for randomization assignment, age, and NYHA functional class. ConclusionsAF ablation, multivalve surgery, and NYHA functional class III/IV were associated with an increased risk for permanent pacing. PPM implantation following MVS was associated with a significant increase in 1-year mortality. (Surgical Ablation Versus No Surgical Ablation for Patients With Atrial Fibrillation Undergoing Mitral Valve Surgery; NCT00903370)

Cardiac electronic implantable devices after tricuspid valve surgery

The demand for tricuspid valve (TV) surgery has increased continuously in the last years. Recent registry data have confirmed that TV repair or replacement carry an increased risk of conduction disorders requiring permanent pacemaker implantation, specifically for patients having multivalve surgery. The implantation of an endocardial right ventricular lead in those patients may impair TV function, and some other approaches may be discussed to avoid traversing the valve. This contemporary review describes the different options currently available for patients requiring pacemaker or defibrillation leads implantation after TV surgery.

Intraoperative tranexamic acid is associated with postoperative stroke in patients undergoing cardiac surgery.

BackgroundStroke is a devastating and potentially preventable complication of cardiac surgery. Tranexamic acid (TXA) is a commonly antifibrinolytic agent in cardiac surgeries with cardiopulmonary bypass (CPB), however, there is concern that it might increase incidence of stroke after cardiac surgery. In this retrospective study, we investigated whether TXA usage could increase postoperative stroke in cardiac surgery.MethodsA retrospective study was conducted from January 1, 2010, to December 31, 2015, in 2,016 patients undergoing cardiac surgery, 664 patients received intravenous TXA infusion and 1,352 patients did not receive any antifibrinolytic agent. Univariate and propensity-weighted multivariate regression analysis were applied for data analysis.ResultsIntraoperative TXA administration was associated with postoperative stroke (1.7% vs. 0.5%; adjusted OR, 4.11; 95% CI, 1.33 to 12.71; p = 0.014) and coma (adjusted OR, 2.77; 95% CI, 1.06 to 7.26; p = 0.038) in cardiac surgery. As subtype analysis was performed, TXA administration was still associated with postoperative stroke (1.7% vs. 0.3%; adjusted OR, 5.78; 95% CI, 1.34 to 27.89; p = 0.018) in patients undergoing valve surgery or multi-valve surgery only, but was not associated with postoperative stroke (1.7% vs. 1.3%; adjusted OR, 5.21; 95% CI, 0.27 to 101.17; p = 0.276) in patients undergoing CABG surgery only. However, TXA administration was not associated with postoperative mortality (adjusted OR, 1.31; 95% CI, 0.56 to 3.71; p = 0.451), seizure (adjusted OR, 1.13; 95% CI, 0.42 to 3.04; p = 0.816), continuous renal replacement therapy (adjusted OR, 1.36; 95% CI, 0.56 to 3.28; p = 0.495) and resternotomy for postoperative bleeding (adjusted OR, 1.55; 95% CI, 0.55 to 4.30; p = 0.405). No difference was found in postoperative ventilation time (adjusted B, -1.45; SE, 2.33; p = 0.535), length of intensive care unit stay (adjusted B, -0.12; SE, 0.25; p = 0.633) and length of hospital stay (adjusted B, 0.48; SE, 0.58; p = 0.408).ConclusionsBased on the 5-year experience of TXA administration in cardiac surgery with CPB, we found that postoperative stroke was associated with intraoperative TXA administration in patients undergoing cardiac surgery, especially in those undergoing valve surgeries only. This study may suggest that TXA should be administrated according to clear indications after evaluating the bleeding risk in patients undergoing cardiac surgery, especially in those with high stroke risk.

Evolving Practice Trends of Aortic Root Surgery in North America

Aortic-valve sparing (AVS) techniques have emerged as alternatives to composite graft-valve replacement (CVR) for treatment of aortic root aneurysm. This study analyzed recent practice trends of aortic root surgery using the Society of Thoracic Surgeons database. From January 2000 through June 2011, 31,747, Overall patients received AVS (n=3,585/31,747; 11.3%) or CVR (n=28,162/31,747; 88.7%). A High-Risk Subgroup was defined as: age >75 years, endocarditis, aortic stenosis, dialysis, multi-valve surgery, valve reoperation, or emergency/salvage status, and high-risk patients were less likely to receive AVS (n=20,356/31,747 [64.1%]; 6% AVS; unadjusted operative mortality 10.5% AVS and 11.7% CVR). The remaining patients comprised a Low-Risk Subgroup, in which AVS was more common (n=11,388/31,747 [35.9%]; 21% AVS; unadjusted operative mortality 1.4% AVS and 3.1% CVR). Procedural changes over 3 equal time periods (P1-P2-P3) were evaluated by Cochran-Armitage trends analysis. Compared to AVS, Overall CVR patients had worse baseline risk profiles and higher unadjusted operative mortality. In High-Risk patients, AVS mortality was comparable to CVR (10.5% vs 11.7%, p=0.19), but AVS mortality was lower in the Low-Risk group (1.4% vs 3%, p<0.0001). For P1/P2/P3, AVS percentages and trend p-values were: High-Risk (6%/6%/7%, p=0.26) and Low-Risk (12%/21%/25%, p<0.0001). CVR prosthesis type (mechanical/bioprosthesis/homograft) also changed: P1 (63%/22%/15%), P2 (58%/38%/4%), and P3 (53%/44%/3%) (all p<0.0001, except mechanical valves in High-Risk patients p=0.18). Patients receiving CVR tended to have higher risk profiles. AVS increased over time in Low-Risk patients while bioprostheses increased in CVR. Favorable outcomes support the trend toward further expansion of AVS.

Reoperative Multivalve Surgery in Adult Congenital Heart Disease

Repeat operations are common in adult congenital heart disease (ACHD) and valve-related procedures are the most frequent indication for intervention. The purpose of this study is to review a single institution's experience with a large number of patients with ACHD undergoing reoperation requiring multivalve intervention. Data from the most recent repeat median sternotomy of 254 consecutive ACHD patients with simultaneous intervention on 2 or more valves were analyzed. Mean age of 136 (54%) female and 118 (46%) male patients was 37.9 years (range, 18 to 83). Diagnoses were conotruncal anomaly 132 (52%), Ebstein-tricuspid valve 41(16%), pulmonary stenosis and right ventricular outflow tract obstruction 37 (14%), atrioventricular septal defect 22 (9%), and other 22 (9%). It was the second sternotomy in 130 (51%) patients, third in 80 (31%), fourth in 34 (13%), and fifth in 10 (4%). Intervention was on 2 valves in 219 patients (86.2%), 3 in 34 patients (13.4%), and 4 in 1 patient (0.4%). The most common valve combination was tricuspid and pulmonary (117, 43%). Early mortality overall was 4.7% (12 of 254) and 2.9% (7 of 239) after elective operation. Potentially modifiable risk factors identified for early mortality were preoperative hematocrit less than 35 (p=0.01), cross-clamp time (p<0.001), and cardiopulmonary bypass time (p<0.001). Late survival was 96%, 89%, and 77% at 1, 5, and 10 years, respectively. Independent risk factors for late mortality were prolonged ventilation (p=0.002), coronary artery disease (p=0.005), and cardiac injury (p=0.018). The need for simultaneous intervention on multiple valves is relatively common in ACHD, particularly with conotruncal anomalies. Prolonged bypass and cross-clamp times, lower hematocrit, and acquired coronary artery disease are significant predictors of adverse outcome. The number or position of valves requiring intervention did not affect early or late survival.

Sutureless aortic bioprosthesis in severe aortic root calcification: an innovative approach

Aortic valve replacement (AVR) in patients with severe aortic root calcification is technically a very difficult procedure which requires a long cardiopulmonary bypass (CPB) time, especially in patients undergoing complex procedures such as multivalve or valve and coronary surgery. We report a case of successful AVR with an innovative approach in a patient with an extensively calcified aortic root and concomitant tricuspid valve regurgitation who underwent mitral valve replacement 20 years ago.

Management of Anomalous Left Circumflex Artery Encircling the Aortic Annulus in a Patient Undergoing Multivalvular Surgery

The abnormal origin of left circumflex artery from the right sinus of Valsalva with a retroaortic course is a well-known coronary anomaly usually without consequences. In patients undergoing aortic valve replacement, this finding becomes crucial because the left circumflex is at risk of injury during the procedure. The scenario is even more complex in patients undergoing multi-valve surgery. We report the diagnosis and successful operative strategy in a patient with anomalous left circumflex arising from the proximal right sinus of Valsalva undergoing double aortic and tricuspid valve surgery for active bacterial endocarditis.

Management of patients undergoing multivalvular surgery for carcinoid heart disease: the role of the anaesthetist

BackgroundThe management of patients with carcinoid heart disease poses two major challenges for the anaesthetist: carcinoid crisis and low cardiac output secondary to right ventricular (RV) failure. Carcinoid crises may be precipitated by the administration of catecholamines and histamine-releasing drugs. MethodsWe analysed a series of 11 patients [six males, median (range) age 60 (42–73) yr] with severe symptomatic carcinoid heart disease who underwent multivalve surgery (right-sided valves, n=8; right- and left-sided valves, n=3) between 2001 and 2007. ResultsAll patients received octreotide intraoperatively [650 (300–1050) μg] to prevent carcinoid symptoms and vasoplegia. Those patients on a greater preoperative octreotide regime required additional intraoperative octreotide [median (range) dose 320 (300–850) vs 750 (650–1050) μg]. Similarly, the use of greater doses of aprotinin (>5 KIU) was associated with greater requirements for octreotide [475 (300–700) vs 750 (320–1050) μg] and higher glucose levels (≥8.5 mmol litre−1). Catecholamines were generally required in those patients who presented with a worse New York Heart Association functional class. Overall mortality was 18% (n=2) and only one episode of mild intraoperative carcinoid crisis was observed. ConclusionsCarcinoid crisis and RV failure still remain the primary challenges for the anaesthesiologist while managing patients with carcinoid heart disease. Our study supports the administration of catecholamines to wean patients off cardiopulmonary bypass, particularly in the presence of myocardial dysfunction. Those patients on higher octreotide dosages may require close intraoperative glucose monitoring. Despite high operative mortality, surgical outcome has been improved potentially due to earlier patient referral and better perioperative management.