Redo Sternotomy Research Articles

Use of adenosine diphosphate receptor inhibitor prior to left ventricular assist device implantation is not associated with increased bleeding

Current guidelines recommend adenosine diphosphate receptor inhibitors (ADPRi) be discontinued 5-7days prior to cardiac surgery due to increased bleeding events, rates of re-exploration, and transfusions. However, the risks of left ventricular assist device (LVAD) implantation in patients taking an ADPRi have not previously been studied. We retrospectively identified 134 eligible patients with ischemic cardiomyopathy that underwent LVAD implantation between July 2009 and August 2013. The cohorts received an ADPRi ≤5days of surgery (n=25) versus >5days prior or not at all (n=109). Subgroup analyses adjusted for differences in frequency of redo sternotomy between cohorts, excluded patients that received an ADPRi >1year prior to surgery, and excluded patients with a redo sternotomy. The ADPRi and control groups did not have significant differences in the primary outcomes, intraoperative PRBC units transfused (3.0 vs. 4.0, p=0.12) or chest tube output within 24h of surgery (1.66 L vs. 1.80 L, p=0.61). After adjusting for differences in frequency of redo sternotomy (ADPRi vs. control, 12 vs. 52%, p≤0.001), no significant difference in PRBC units transfused (3.1 vs. 3.5, p=0.59) or chest tube output (2.04 L vs. 2.04 L, p=0.98) was seen. No significant difference in 30-day mortality (8.0 vs. 11.0%, p=0.63), 90-day mortality (16.4 vs. 23.3%, p=0.42), or length of stay (29.0 vs. 28.0, p = 0.61) was seen. In this single-center experience, use of an ADPRi ≤5days prior to LVAD implantation was not associated with increased bleeding, length of stay, or mortality.

Inner-Branched Endografts for the Treatment of Aortic Arch Aneurysms After Open Ascending Aortic Replacement for Type A Dissection

The development of a postdissection aortic arch aneurysm after open ascending aortic replacement for type A dissection places the patient at increased risk for an open operation due to the need for redo sternotomy and total arch replacement. We conducted a computed tomography-based feasibility study to assess what proportion of these patients would be anatomically suitable for branched endograft repair of an arch aneurysm. We also aimed to identify ways to tailor the index operation to increase suitability for future endovascular repair. Our study was conducted at the Aortic Centre, Lille University Hospital, Lille, France. Postoperative images were assessed for patients after open replacement of the ascending aorta for acute type A dissection in this center between 2009 and 2015 to determine suitability for use of an aortic arch inner-branched device. The assessment found 52 of 73 patients (71.2%) were anatomically suitable for treatment with the aortic arch inner-branched device. The only cause for absolute exclusion from suitability was the absence of a proximal landing zone in the ascending aorta. Reasons for this were the ascending aortic graft being too short (71.4%), the presence of a major kink in the graft (23.8%), and the graft diameter being too large (4.8%). Approximately 70% of patients with arch aneurysm formation after open ascending aortic replacement for type A dissection are anatomically suitable for treatment with the aortic arch inner-branched device. In the future, surgeons will be able to fashion the prosthetic graft at the time of the index operation to ensure it fulfills criteria for an adequate proximal landing zone.

Assessment of Risk Factors for a Sustainable “On-Table Extubation” Program in Pediatric Congenital Cardiac Surgery: 5-Year Experience

To delineate risk factors for failure of extubation in the operating room among pediatric cardiac surgery patients. Prospective, observational study. Single center, tertiary care, teaching hospital. The study comprised 448 congenital cardiac surgery patients who were enrolled for intended extubation in the pediatric cardiac operating room over 5 years. The airways of enrolled patients were extubated in the operating room if predetermined suitability criteria were met. If the criteria were not met, patients were transferred to the intensive care unit with an endotracheal tube in situ. Patients whose airways were extubated successfully were followed up to determine specifically whether reintubation or use of noninvasive ventilation was necessary post-procedure. The airways of 92% (412) patients were extubated in the operating room. Incidence of reintubation in the intensive care unit was 2.4%. There were 4 mortalities in the whole group. A 100% success rate for operating room extubation was achieved for patients in Risk Adjusted Congenital Heart Surgery category 1, and patients undergoing adult congenital cardiac disease surgery and redo sternotomy. The airways of 85% of patients with preoperative pulmonary hypertension were extubated in the operating room. Statistical analysis was applied to identify risk factors present in the group that made extubation in the operating room unachievable. Extubation in the operating room was successful in a majority of patients undergoing cardiac surgery. Multivariate analysis identified weight<5 kg, age<1 year, cardiopulmonary bypass time>120 minutes, and presence of significant noncardiac structural anomalies as significant factors affecting extubation in the operating room, with an adjusted odds ratio (95% confidence interval) of 10 (2.7-37), 7.2 (2-22), 5.5 (1.7-17.7), and 3.3 (1.2-9.3), respectively. Pulmonary hypertension, redo sternotomy, higher Risk Adjusted Congenital Heart Surgery category, and aortic clamp time>60 minutes did not achieve significance in the multivariate analysis as risk factors for extubation in the operating room.

Renal cell carcinoma with thrombus extending to the hepatic veins or right atrium: operative strategies based on 41 consecutive patients.

The natural history of renal cell carcinoma (RCC) with tumour thrombus extending at or above the hepatic veins is dismal. Different surgical approaches have been described including cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest. We here report our experience in terms of surgical techniques and outcomes on 41 consecutive patients presenting an RCC extending to the hepatic veins or the right atrium. A surgical decision-making algorithm is discussed. Retrospective review of 41 patients operated for RCC extending in the retrohepatic vena cava (extent level III-IV) between 2000 and 2015. Patients were operated by a dedicated urology/cardiac surgery team. The mean age was 62.6 ± 10.4 years; 39% were female. Surgery was emergent in 7.3% of patients, 2.4% of patients had preoperative dialysis, 4.9% required a redo sternotomy and 19.5% had coronary artery disease. Tumour thrombus extended above the diaphragm in 23 patients (level IV) and to the level of hepatic veins (level III) in 18 patients. CPB was used in 38 patients. Arterial cannulation was in the aorta or femoral artery in 14 patients during the initial experience. In the current era, the axillary artery and the innominate artery were used in 12 patients each. Mean CPB, cross-clamp and circulatory arrest times were, respectively, 96.5 ± 42.9, 21.1 ± 16.4 and 10.2 ± 8.2 min (mean temperature of 25.7 ± 4.9°C). Hepatic exclusion without the use of CPB was performed to excise the thrombus in 3 patients. A right nephrectomy was performed in 25 patients, a left in 15 patients and a bilateral nephrectomy in 1 patient. Five patients had a partial inferior vena cava (IVC) resection, with 4 patients requiring a patch reconstruction of the IVC. Three patients had an infrarenal IVC ligation. One patient suffered a cerebrovascular accident in the postoperative period. One in-hospital death occurred (in-hospital mortality 2.4%). The mean follow-up was 1.9 ± 2.0 years. Twenty-three patients died during follow-up; 21 were disease-related. Three-year survival rate was 37.1%. High-level RCC tumour thrombus is a rare clinical entity, the treatment of which is complex and requires dedicated operative teams. The operative technique should be tailored according to the level of extension and the extent of vena cava obstruction/occlusion of the tumour thrombus. Contemporary operative techniques may be conducted with excellent results. Mid-term survival is limited, supporting the necessity to pursue research efforts towards establishing effective adjunct therapies.

Innominate Artery Cannulation Access in Pediatric Patients Undergoing Redo Sternotomy

Redo sternotomy in pediatric patients can be complicated due to the unsuitability of many arterial cannulation sites for the pediatric population. Innominate artery cannulation provides a safe and easily reproducible alternative and prevents many of the disadvantages seen in femoral and axillary artery cannulation. Its use in pediatric cardiac surgery has seen a rise [1]. Herein, we describe the technique for innominate artery cannulation in pediatric patients undergoing redo sternotomy and review our experience with the technique.

Robotic Left Ventricular Assist Device Implantation Using Left Thoracotomy Approach in Patients with Previous Sternotomies.

Left ventricular assist devices (LVADs) are commonly used as either a bridge-to-transplant or a destination therapy. The traditional approach for LVAD implantation is via median sternotomy, but many candidates for this procedure have a history of failed cardiac surgeries and previous sternotomy. Redo sternotomy increases the risk of heart surgery, particularly in the setting of advanced heart failure. Robotics facilitates a less invasive approach to LVAD implantation that circumvents some of the morbidity associated with a redo sternotomy. We compared the outcomes of all patients at our institution who underwent LVAD implantation via either a traditional sternotomy or using robotic assistance. The robotic cohort showed reduced resource utilization including length of hospital stay and use of blood products. As the appropriate candidates become elucidated, robotic assistance may improve the safety and cost-effectiveness of reoperative LVAD surgery.

Hybrid Aortic Repair of Dissecting Aortic Arch Aneurysm after Surgical Treatment of Acute Type A Dissection

The aim of this study was to evaluate the short-term and midterm results of hybrid repair of dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections. Between 2003 and 2014, 7 consecutive patients, previously operated for acute type A dissection, underwent hybrid repair of their aortic arch for a dissecting aortic arch aneurysm (6 men, mean age 62 ± 11 years). Aneurysm formation requiring treatment in these aortic arches was observed from 2 to 20 years after the initial aortic dissection repair. A hybrid technique was used in all patients, with supra-aortic debranching through a redo sternotomy and either simultaneous (6 patients) or staged endovascular stent grafting (1 patient). Two patients were treated in an emergent setting (1 ruptured and 1 symptomatic aneurysm). Two patients required a more extensive aortic repair of either the thoracic aorta (n, 1) or of the thoracoabdominal aorta (n, 1). One patient underwent, saphenous vein bypass from the ascending aorta to the anterior descending coronary artery on full cardiopulmonary bypass. Follow-up computed tomography scans were performed at 1 week, 3, and 6 months, and annually thereafter. Technical success was achieved in all the cases. One transient ischemic attack, 1 stroke, and 1 episode of transient spinal cord ischemia were observed. Thirty-day mortality was not observed. A type I endoleak at 6 months was successfully treated with deployment of a second stent graft. After a mean follow-up of 3.5 ± 3.1 years (range, 0.4-9.6 years), no aortic-related mortality was observed. No cases of stent-graft migration or secondary rupture were observed. Our experience demonstrates the promising potential of endovascular repair of dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. The potential to diminish the magnitude of the surgical procedure and the consequences of aortic arch exposure, and above all avoiding the need for circulatory arrest are promising and mandate further investigation to determine the efficacy and durability of this technique.

Giant Coronary Ostial Aneurysms after Aortic Root Replacement

A 36-year-old man with Marfan’s Syndrome underwent aortic root replacement 21 years previously. A 29 mm St Jude valve conduit was used, anastomosing the coronary arteries to the composite valve graft using the ‘‘button’’ technique. He presented recently with worsening of long-standing back pain. As part of the investigations a CT angiogram was performed (Figure 1). This demonstrated aneurysms of the coronary buttons, (right 34 x 40 mm and left 19 x 17 mm) in the axial plane. It also demonstrated an infra-renal inflammatory abdominal aortic aneurysm, which was treated via open repair prior to the repeat cardiac surgery. An echocardiogram showed satisfactory function of the St Jude aortic valve. A redo sternotomy was performed and cardiopulmonary bypass established through the aorta and right atrium (Figure 2). The heart was protected by antegrade and retrograde cardioplegia. The two aneurysms were carefully dissected and then removed together with most of the original dacron graft leaving a small rim of dacron

HYPERNEPHROMA EXTENDING IN THE RETROHEPATIC VENA CAVA SUS-HEPATIC VEINS OR RIGHT ATRIUM: SURGICAL TECHNIQUES AND OUTCOMES IN 41 PATIENTS

The natural history of hypernephroma with tumoral thrombus extending within the retrohepatic vena cava is dismal. Classic operative treatment consists of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest. We herein report our experience in terms of surgical techniques and outcomes in 41 consecutive patients presenting a hypernephroma extending in the retrohepatic vena cava at the level of the sus-hepatic veins or the right atrium. Retrospective review of 41 patients operated for hypernephroma extending in the retrohepatic vena cava sus-hepatic veins/right atrium between 2000 and 2015. Patients operated by a dedicated urology/cardiac surgical team. Mean age was 62.6±10.4; 39% female. Surgery was emergent in 7.3% of patients, 2.4% of patients had pre-op dialysis, 4.9% required redo sternotomy and 19.5% had CAD. Tumor thrombus extended to the right atrium in 23pts and to the level of sus-hepatic veins in 18pts. CPB was used in 38pts; mean CPB time 96,5 ± 42,9 min. Mean aortic cross clamp time was 21,1 ± 16,4min. Arterial cannulation was in the aorta or femoral artery in 14pts during the initial experience. In the current era, the axillary artery and the innominate artery were used in 12 pts respectively. Circulatory arrest was performed in 36pts; mean duration of 10,2 ±8,2min at a mean temp of 25.9oC. Cerebral perfusion was antegrade in 25pts, retrograde in 2 pts and hypothermia alone in 9pts. Non-CPB with hepatic exclusion was performed to excise the tumoral thrombus in 3pts. A right nephrectomy was performed in 25pts, a left in 15 pts and bilateral nephrectomy in 1 pt. Four patients had partial vena cava resection with reconstruction. Three patients had an IVC ligation and 5pts had a partial IVC resection. One patient suffered a CVA in the postoperative period. One in-hospital death occurred. Mean follow up time was 1.9±2.0 years. Twenty-two patients died during follow up; 21 were disease related. Three years survival rate was 37.1%. Hypernephroma with extension in the retrohepatic vena cava/right atrium is a rare clinical entity which treatment is complex thus requires dedicated operative teams. Operative technique should be tailored to the patient’s tumor extension and the extent of vena cava obstruction by the tumor. Perioperative results may be conducted with excellent results. Mid-term survival is limited supporting the necessity to pursue research efforts towards effective adjunct therapies.

Pressurized Cadaver Model in Cardiothoracic Surgical Simulation

Simulation is increasingly recognized as an integral aspect of thoracic surgery education. A number of simulators have been introduced to teach component cardiothoracic skills; however, no good model exists for numerous essential skills including redo sternotomy and internal mammary artery takedown. These procedures are often relegated to thoracic surgery residents but have significant negative implications if performed incorrectly. Fresh tissue dissection is recognized as the gold standard for surgical simulation, but the lack of circulating blood volume limits surgical realism. Our aim is to describe the technique of the pressurized cadaver for use in cardiothoracic surgical procedures, focusing on internal mammary artery takedown.

Contemporary Outcomes of Repeat Aortic Valve Replacement: A Benchmark for Transcatheter Valve-in-Valve Procedures

Reoperative aortic valve replacement (re-AVR) after previous AVR is a complex procedure involving redo sternotomy and removal of a previous prosthesis. With increasing use of valve-in-valve transcatheter aortic valve replacement for failed aortic bioprostheses, an evaluation of contemporary outcomes of re-AVR in patients with bioprostheses is warranted. The study included 3,380 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (July 2011 to September 2013) who underwent elective, isolated re-AVR after a previous AVR. Outcomes in these patients were compared with those of 54,183 patients with isolated primary AVR during the same period. A subgroup analysis of explanted bioprostheses in re-AVR (previous bioprosthetic valve: n= 2,213) was performed. Re-AVR patients were younger (66 vs 70 years, p < 0.001) compared with primary AVR patients. Re-AVR was associated with higher operative mortality (4.6% vs 2.2%, p < 0.0001), composite operative mortality and major morbidity (21.6% vs 11.8%, p < 0.0001), postoperative stroke (1.9% vs 1.4%, p= 0.02), postoperative aortic insufficiency mild or greater (2.8% vs 1.7%, p < 0.0001), pacemaker requirement (11.0% vs 4.3%, p < 0.0001), and vascular complications (0.06% vs 0.01%, p= 0.04). For the explanted previous bioprosthetic valve group, operative mortality was 4.7%, composite outcome was 21.9%, stroke rate was 1.8%, and pacemaker requirement was 11.5%. Re-AVR is now performed with an acceptable operative mortality, which is higher than primary AVR. The overall incidence of stroke, vascular complication, and postoperative aortic insufficiency was low although higher than primary AVR. These results may serve as a benchmark for future analysis of valve-in-valve transcatheter aortic valve replacement and may have an effect on future choice of transcatheter aortic valve replacement vs re-AVR.

Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation

Orthotopic heart transplantation (OHT) remains the gold standard for end-stage heart failure. However, donor availability is severely limited. With a median wait time of 6.6 months and more than 12% of patients waiting 5 or more years, the decision is often made to implant a left ventricular assist device (LVAD) asa bridge to transplantation for medical stabilization. Furthermore, the number of patients who have had at least one prior sternotomy while awaiting transplantation is increasing. Previous studies have indicated reoperative sternotomy as a risk factor for compromised survival. Concerns are specifically focused on perioperative, short-term, and long-term outcomes after LVAD explantation or redo sternotomy before OHT because of increasing operative complexity. We hypothesize that despite the greater technical difficulty caused by LVAD explantation or redo sternotomy, outcomes would not be compromised. We retrospectively analyzed patients who underwent OHT at the University of Pennsylvania during a 5-year period (2008-2013; n= 253). All patients who underwent a bridge to transplantation LVAD (n= 72) or prior sternotomy (n= 65) were compared with those undergoing OHT with a virgin chest (n= 116). Preoperative, intraoperative, and postoperative variables were analyzed. Short- and long-term survival were studied (minimum follow-up, 6 months). Comorbidities were similar among the groups. There was no difference in donor allograft ischemic time (p= 0.6). However, cardiopulmonary bypass time was longer in both bridge to transplantation and prior sternotomy cohorts (p < 0.00001). The blood transfusion requirement was higher in bridge to transplantation (12.5 ± 13.7 units; p= 0.0007) and prior sternotomy groups (11.7 ± 12.9 units; p= 0.02) as compared with the virgin chest cohort (7.1 ± 10.7 units). For bridge to transplantation, both time to extubation (1.0 ± 1.6 versus 0.9 ± 1.0 days; p= 0.03) and intensive care unit length of stay (7.0 ± 7.0 versus 6.0 ± 7.0 days; p= 0.06) were longer compared with the virgin chest cohort. The same was true for prior sternotomy (extubation time, 1.9 ± 4.4 days; p= 0.005; intensive care unit length of stay, 8.0 ± 12.0 days; p= 0.06). There was no difference in hospital length of stay (p= 0.2). Overall, there was no difference in short- or long-term survival. Implantation of an LVAD as a bridge to transplantation or prior sternotomy does not adversely impact allograft function, hospital length of stay, or long-term outcomes after OHT. The decision to manage a patient medically while awaiting transplantation versus an LVAD bridge strategy should not be limited by concerns of subsequent poor outcomes after transplantation.

Minimally Invasive Port Access Approach for Reoperations on the Mitral Valve

In patients requiring a second-time or more operation on the mitral valve (MV), we assessed whether the outcomes of the minimally invasive port access approach (port access group) were equivalent to those of the traditional redo sternotomy approach (redo sternotomy group). In a retrospective review (1998-2011), 409 patients had previous MV operations requiring a second-time or more MV reintervention. Of those, 67 patients had the port access approach, and 342 had the redo sternotomy approach. Of the latter, 220 met the inclusion criteria because emergencies, patients with endocarditis, and those requiring concomitant procedures involving aortic valve and aorta were excluded. New York Heart Association class 2 or above, age, atrial fibrillation, and surgical indications were similar in both groups. The port access group had more patients with previous MV repair (78% [n = 52] vs 41% [n = 90], p < 0.01) than with MV replacement (19% [n = 13) vs 53% [n = 116], p < 0.01). Concomitant procedures were similar (20% [n = 14] vs 27% [n = 59], p = 0.4). The MV re-repair rates were similar (19% [n = 10] vs 22% [n = 20], p = 1). The cardiopulmonary bypass times (153 ± 42 minutes vs 172 ± 83 minutes, p = 0.07) and aortic cross-clamping times (104 ± 38 minutes versus 130 ± 71 minutes, p < 0.01) were lower in the port access group. Mortality was lower in the port access group, although not significantly (3.0% [n = 2] vs 6.0% [n = 13], p = 0.5). The rates of postoperative stroke were similar (3.0% [n = 2] vs 3.2% [n = 7], p = 1). On postoperative echocardiography, freedom from mitral regurgitation >2+ was 100% in the port access group and 99% in the redo sternotomy group. The mean hospital length of stay was 11 ± 15 days versus 14 ± 12 days (p = 0.07). The port access approach can be safely adopted for reoperations on the MV without compromising postoperative mortality or MV function.

Dynamic Four-dimensional Computed Tomography (4D CT) Imaging for Re-entry Risk Assessment in Re-do Sternotomy - First experience

Repeat cardiac surgeries are well known to have higher rates of complications, one of the important reasons being injuries associated with re-do sternotomy. Routine imaging with CT can help to minimise this risk by pre-operatively assessing the anatomical relation between the sternum and the underlying cardiovascular structures, but is limited by its inability to determine the presence and severity of functional tethering and adhesions between these structures. However, with the evolution of wide area detector MD CT scanners, it is possible to assess the presence of tethering using the dynamic four-dimensional CT (4D CT) imaging technique. Nineteen patients undergoing re-do cardiac surgery were pre-operatively imaged using dynamic 4D CT during regulated respiration. The datasets were assessed in cine mode for presence of differential motion between sternum and underlying cardiovascular structures which indicates lack of significant tethering. Overall, there was excellent correlation between preoperative imaging and intraoperative findings. The technique enabled our surgeons to meticulously plan the procedures and to avoid re-entry related injuries. Our initial experience shows that dynamic 4D CT is useful in risk stratification prior to re-do sternotomy by determining the presence or absence of tethering between sternum and underlying structures based on assessment of differential motion. Furthermore we determined the technique to be superior to non-dynamic assessment of retrocardiac tethering.

Redo ‘beating heart’ minimally invasive mitral valve surgery – An Australian experience

Redo cardiac surgery is becoming increasingly prevalent as the population ages. Re-entry median sternotomy is associated with significant potential morbidity and mortality, especially if patent coronary artery grafts are present(1). Dissection of adhesions can be time-consuming and technically challenging, especially if the aorta must be exposed for cannulation or cross-clamping. However, in most cases of redo cardiac surgery, the right pleura will be previously untouched. In addition, in patients with poor ventricular function, as is often seen in long-standing valvular disease or history of coronary artery disease, myocardial protection becomes a concern and cardiac arrest will place the patient at risk of ischaemia-reperfusion injury and postoperative low cardiac output(2). In cases of redo surgery for mitral valve intervention, a right anterolateral thoracotomy incision with surgery done on a ‘beating heart’, provides excellent exposure while avoiding the risk of redo sternotomy, limits the need for extensive adhesiolysis, and cardioplegia reperfusion injury. From 2006 to 2013, 25 cases of reoperative mitral valve surgeries were performed on patients through a right thoracotomy utilising a no cross-clamp, beating heart approach. Preoperative patient factors, perioperative outcomes, as well as complication rates, were identified through retrospective case note review. Our technique of redo mitral valve surgery through a right mini-thoracotomy approach, performed on a beating heart, was introduced as a means to facilitate simpler operations with shorter CPB and overall operation times, reduce adhesiolysis, and minimise ischaemia-reperfusion injuries. This series has shown it to be a safe and effective option for cardiac surgeons.

Alternative access for balloon-expandable transcatheter aortic valve replacement: Comparison of the transaortic approach using right anterior thoracotomy to partial J-sternotomy

For transcatheter aortic valve replacement (TAVR), transaortic (TAo) and transapical (TA) approaches are major alternatives in cases unsuitable for the transfemoral approach. Partial J-sternotomy is a widely used access for TAo. However, redo sternotomy or right-sided aorta may preclude this access, and right anterior thoracotomy is potentially beneficial in these cases. This study sought to evaluate the TAo approach using thoracotomy (T-TAo) and compare it to the TAo approach using a sternotomy (S-TAo) and a TA approach. In a large single-center series, consecutive TAVR patients were studied. Procedural/clinical outcomes of the T-TAo, S-TAo, and TA groups were compared up to a 30 days follow-up period. Of 872 TAVR patients, 22 (2.5%) were T-TAo, 29 (3.3%) were S-TAo, and 86 (9.9%) were TA approaches. The TA group showed the shortest intensive care unit stay, with a median 2.0 (interquartile range 1.0-3.0) days: for T-TAo it was 3.0 (2.0-5.3) and for S-TAo, 3.0 (3.5-5.0) (P < .001). Although it was not statistically significant, the T-TAo group showed numerically less mortality (1 [4.5%], 5 [17.9%], and 8 [9.4%] in the T-TAo, S-TAo, and TA groups, respectively; P = .30), with no difference in other endpoints, including stroke/transient ischemic attack, rehospitalization, and paravalvular leak. Additionally, computed tomographic assessment revealed that T-TAo facilitated a more coaxial approach than S-TAo: 20.4° ± 8.2° versus 30.6° ± 8.2° (P < .001). T-TAo is a feasible approach that can provide greater coaxiality. This option allows tailored and optimal access to the individual patient and facilitates a treatment strategy in nontransfemoral TAVR patients.

176-I * TRANSAPICAL APPROACH IN REDO MYECTOMY FOR HYPERTROPHIC CARDIOMYOPATHY

Objectives: Reoperation for recurrent or residual gradients after septal myectomy offers symptomatic relief and restores life span. In selected patients, septal myectomy needs to be performed through a transapical approach. Methods: We present the case of a 35-year-old female that underwent transaortic septal myectomy 2 years ago. She presented with class IV symptoms and significant residual obstruction. Additionally she had severe tricuspid regurgitation secondary to an internal cardiodefibrillator lead. Echocardiographic evaluation demonstrated subaortic and midventricular obstruction. We describe our surgical approach. Results: She underwent redo sternotomy and tricuspid valve repair. A repeat transaortic myectomy was attempted but exposure of septum was not appropriate and we performed a midventricular and low subaortic septal myectomy through an apical incision. Conclusion: Transapical septal myectomy is safe and provides excellent exposure for midventricular obstruction relief. In selected patients with difficult transaortic exposure it may allow basal myectomy. Complete relief of obstruction improves symptoms.

Aortic Valve Replacement in Octogenarians With Prior Cardiac Surgery

Transcatheter aortic valve implantation (TAVI) has been advocated for very elderly patients with aortic stenosis, and prior cardiac surgery as a less invasive treatment option. Although surgical aortic valve replacement (AVR) is safe and effective in selected elderly patients, the perioperative and mid-term outcomes of AVR in very elderly with prior cardiac surgery are unknown. The Society of Thoracic Surgeons (STS) Database at our center enrolled 3,735 patients after AVR since 1997. In this time interval, we identified 61 patients 80 years and older who underwent AVR for severe AS or failed aortic bioprosthesis after having prior cardiac surgery. All clinical parameters were derived from the STS database. Follow-up mortality was assessed using the Social Security Death Index. The average age of the patients was 83 ± 2 years, 77% were male, and 75% underwent an isolated coronary artery bypass graft (CABG) as their first cardiac procedure. The mean ejection fraction was 0.53 ± 0.13. The CABG was performed concurrently in 49% of patients at the time of redo sternotomy and AVR. Stented bioprosthesis was implanted in 61% of patients and stentless in 39%. Perioperative mortality was 1.6% (1 of 61). One, 3, 5, and 7 year survival rates were 85%, 69%, 63%, and 43%, respectively. Patients with AVR only had similar survival to patients who underwent concomitant AVR and CABG. Type of aortic prosthesis did not influence postoperative survival. In selected patients over the age of 80 with history of prior cardiac surgery, AVR can be performed safely with very good mid-term outcomes. Age alone should not be exclusion criteria for surgical AVR in octogenarians with prior cardiac surgery.

Right Ventricular Assist Device Support After Continuous Flow Left Ventricular Assist Device Implantation: Predicting a Poor Predictor.

Purpose: Demographic, perioperative and late clinical outcomes in patients who require right ventricular assist device (RVAD) support after left ventricular assist device (LVAD) implantation, has not been well described. Predictive tools of RVAD after LVAD are based on univariate models from combined pulsatile and continuous flow (CF) VAD patients. Multivariable models have been inconsistent in predictors elucidated. We aimed to review contemporary CF LVADs with long term follow-up, to determine the predictors of RVAD need after CF LVAD, and the impact on mid and long term survival. Methods: A retrospective review of a single center was done. All HeartMate II CF LVADs (2003-2012) were identified. Patients were stratified by whether they received a RVAD after LVAD implant. Descriptive univariate statistics, multivariate regression and survival analysis were performed. Results: We identified 294 patients; 26 (8.8%) required a RVAD. Mean follow up was 2.5 years (maximum 8 years). Late survival was worse in those who received a RVAD (15% vs 76%, p<0.001). Receiving an RVAD was an independent predictor of mortality (HR 2.4, 95% CI 3.7-40, p<0.001). Patients who required a RVAD had similar demographics and preoperative characteristics, however more likely to be: bridge to transplant (69% vs 46%, p=0.03), intubated pre-operatively (31% vs 12%, p=0.008), on temporary circulatory support preop (27% vs 8%, p=0.09) and had higher preoperative bilirubin and AST. RVAD patients more often required redo sternotomy (69% vs 39%, p=0.003). In-hospital outcomes included longer ventilator support (30+50 vs 9+17 days, p<0.001). Multivariable regression analysis found significant independent predictors of getting a RVAD after LVAD implant to be redo sternotomy (HR 1.5, 95% CI 1.3-9.3, p=0.002) and pre-operative temporary circulatory support (HR 1.3, 95% CI 1.2-9.6, p=0.01). Conclusion: This is the largest series of patients with contemporary CF LVADs and long term follow-up. RVAD requirement after LVAD purports very poor early, mid and long term survival. Redo sternotomy and pre-operative temporary circulatory support were independent predictors of RVAD requirement, which along with univariate variables identified above, may be used to identify and stratify this high risk cohort.

Mid and Late Outcomes Support Use of Contemporary Continuous Flow Left Ventricular Assist Devices in the Elderly.

PURPOSE: End stage heart failure in the elderly is one of few growing cohorts in cardiac surgery. We reviewed a large group of elderly patients’ mid and long term results with contemporary continuous flow left ventricular assist devices (CF LVAD). METHODS: We performed a retrospective review of a single center identifying all patients with approved HeartMate II CF LVADs (2003-2012). Patients were divided into < 65 versus > 65 years. Descriptive statistics and multivariate regression was done. RESULTS: Demographic, perioperative characteristics and outcomes of 300 patients are shown in Table 1. Mean follow-up in both groups was 2 years (max 8 yrs). Patients > 65 were more likely ischemic etiology and required redo sternotomy. They were less likely to have their LVAD explanted and spent less time in ICU. There was no significant difference in mortality (Figure 1) or other clinical outcomes (Table 1). Age > 65 was not a risk factor for mortality (HR 1.2, 95% CI 0.6-2.6, p=0.5) however redo surgery was (HR 1.7, 95% CI 1.1-2.9, p=0.04). Sensitivity analyses at age thresholds found significant divergence in survival curves at 70 years, however age did not emerge as an independent predictor of mortality and the cohort sample was not sufficient for meaningful conclusions. CONCLUSIONS: This is a large cohort of contemporary patients with CF LVADs with the longest follow-up in the literature. CF LVADs are an effective safe option in elderly; age is less likely an issue versus poor protoplasm or complex operations such as redo cardiac operations.Table: No Caption available.Figure: No Caption available.