Valve Procedures Research Articles

Physiological Ventricular Simulator for Valve Surgery Training

Surgical simulation is becoming increasingly important in training cardiac surgeons. However, there are currently no training simulators capable of testing the quality of simulated heart valve procedures under dynamic physiologic conditions. Here we describe a dynamic ventricular simulator, consisting of a 3D printed valve suspension chamber and a model 1423 Harvard apparatus pulsatile pump, which can provide close to physiologic hemodynamic perfusion of porcine aortic roots attached to the valve chamber for education and training in cardiac surgery. The simulator was validated by using it to test aortic valve leaflet repairs (n = 6) and aortic valve replacements (n = 3) that were performed by two trainees. Procedural success could be evaluated by direct visualization of the opening and closing valve, hemodynamic measurements and echocardiography. We conclude that, unlike other methods of simulation, this novel ventricular simulator is able to test the functional efficacy of aortic procedures under dynamic physiologic conditions using clinically relevant echocardiographic and hemodynamic outcomes. While validated for valve surgery, other potential applications include ascending aortic interventions, coronary re-implantation or catheter-based valve replacements.

Highlights on mitral annular motion after aortic valve procedures.

Journal of Cardiac SurgeryEarly View COMMENTARY Highlights on mitral annular motion after aortic valve procedures Ignazio Condello PhD, Corresponding Author Ignazio Condello PhD ignicondello@hotmail.it orcid.org/0000-0003-1192-1908 Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy Correspondence: Ignazio Condello, PhD, GVM Care & Research, Perfusion Service, Anthea Hospital, Via Camillo Rosalba 35/37, 70124 Bari, Italy. Email: ignicondello@hotmail.itSearch for more papers by this authorGiuseppe Nasso MD, Giuseppe Nasso MD orcid.org/0000-0002-3519-770X Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, ItalySearch for more papers by this author Ignazio Condello PhD, Corresponding Author Ignazio Condello PhD ignicondello@hotmail.it orcid.org/0000-0003-1192-1908 Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy Correspondence: Ignazio Condello, PhD, GVM Care & Research, Perfusion Service, Anthea Hospital, Via Camillo Rosalba 35/37, 70124 Bari, Italy. Email: ignicondello@hotmail.itSearch for more papers by this authorGiuseppe Nasso MD, Giuseppe Nasso MD orcid.org/0000-0002-3519-770X Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, ItalySearch for more papers by this author First published: 11 June 2022 https://doi.org/10.1111/jocs.16678Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Successful aortic root enlargement procedure in low resource setting: Two rare cases.

BackgroundSmall aortic root is an unexpected incident during surgical aortic valve replacement in which the prosthesis valve size does not match the case being treated.Case presentationTwo patient-prosthesis mismatches with aortic valve problems underwent surgical aortic valve replacement. Based on calculating the body surface area (BSA) and effective orifice area (iEOA), the selection of prosthesis valve size was determined. When minor aortic root surgery was performed, it was discovered that the procedure of aortic root enlargement had to be conducted. The surgery went smoothly, but both patients had different outputs. The first patient was dead, while the second patient had a better quality of life.DiscussionEvery surgical aortic valve replacement preparation of aortic root enlargement procedure needs to be prepared for the worst-case scenario.ConclusionAortic root enlargement procedure must be anticipated in aortic valve replacement, especially for the patients with small aortic roots, both isolated and with concomitant valve procedure.

Clinical outcomes of pulmonary valve replacement surgery in pediatrics: a single-center experience long-term study

Introduction: Heart valve disease in pediatricsis an increasing global concern, especially in developing countries. This study aims to determine the clinical outcomes of pulmonary valve replacement (PVR) surgery in pediatrics. Methods: The authors retrospectively identified all pediatrics undergoing PVR surgery at Imam Reza hospital (Mashhad, Iran) between 2000 and 2020. Their medical records were reviewed for demographic characteristics, clinical data (intra-operative and postoperative), and follow-up results. Echocardiography and electrocardiography were performedonall patients before the surgery and periodically after the surgery. Results: Among 50 pediatrics undergoing surgical PVR, 38 (76%) were female and others were male (14%), with a mean age of 10.39±5.31 years. The leading cause of PVR was the Tetralogy of Fallot. There was a significant relationship between age at the time of surgery and the size of the pulmonary valve(P=0.02).There were also statistically significant differences between QTc intervals before and after surgery (P=0.001). Further more, there was a significant correlation between QTc intervals before and after surgery and the ageof pediatrics at the time of surgery (P=0.01, r=-0.6).There was also a statistically significant relationship between the ICU stay (P=0.01) and the weaning time of the mechanical ventilation (P=0.03). Conclusion: It is recommended that this procedure ispostponed as much as possible to decrease postoperative life-threatening events in pediatrics.In addition, if this surgery is conducted with good surgical and nursing management, it can be safe with low complications among other cardiac valve procedures.

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

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

P53 SURGICAL CUTDOWN VERSUS PERCUTANEOUS ACCESS IN TRANSFEMORAL TAVI: A RETROSPECTIVE SINGLE–CENTER EXPERIENCE

Abstract Background The transfemoral (TF) approach is the most common route in TAVI, but it is still associated with risk of bleeding and vascular complications. Nowadays, it is not evident a clear superiority of percutaneous (PC) versus surgical cutdown (SC) approach. The aim of our retrospective study is to compare the outcomes of the two different types of accesses. Methods From January 2018 to December 2021, 377 patients underwent TF–TAVI. The mean age was of 81,17 ± 8,62 years, with a percentage of female of 55,6%. The mean STS score was of 4,37 ± 2,28. The mean LVEF was of 57,22 ± 9,93%. Forty patients underwent a previous cardiac surgery. Seventeen valve–in–valve procedures were performed. The baseline clinical and echocardiographic data and operative features were prospectively collected. The primary endpoint was 30–day bleeding and vascular complications defined according to VARC–2 criteria. Secondary endpoints were clinical outcomes and in–hospital mortality. The PC group included 246 patients, while the SC group 128 patients. Results The baseline characteristics in the two groups were not statistically different, except for male sex (40,9% vs 52,3% p = 0.04) and NYHA Class III–IV (55,8% vs 25,7% p = 0.00) in PC and SC group, respectively (Table 1 and Table 2). Conclusions The rates of major vascular complications and major bleeding did not differ statistically between the two groups. The SC approach is associated with a significant lower rate of minor vascular complications, but a higher in–hospital mortality. The choice of the access should probably be based on the operator‘s experience and patient‘s vascular anatomy.

P371 1 YEAR OUTCOME OF BICARBON AORTIC MECHANICAL VALVE IN LOW–INR REGIMEN: RESULTS FROM SURE–AVR REGISTRY

Abstract Background The drawback of using mechanical valve is lifelong anticoagulation use, and close monitoring is required to prevent postoperative complications, including thromboembolism and anticoagulation–related bleeding. Moderate anticoagulation after mechanical heart valve replacement has been proposed to reduce these risks. The present study aimed to evaluate the safety and feasibility of reduced oral anticoagulation after Bicarbon aortic mechanical valve replacement. Methods SURE–AVR is a propsective, multinational registry of patients undergoing aortic valve replacement. Between July 2018 and October 2020, among subjects undergoing AVR with Bicarbon valve in the SURE–AVR registry, 108 were assigned at discharge to low–INr regimen (international normalized ratio 1.5–2.5). Mean INr at discharge was 1.8+/–0.5 and 2.2+/–0.4 at 1 year. in–hospital and post–discharge outcomes up to 1 years were collected. The mean age was 55.5 +/–10.6 years old (range 25–82). Concomitant procedures included coronary artery bypass grafting (14.6%), mitral valve procedure (3.7%) and myectomy (1.9%). The follow–up duration averaged 1 year (361.8 +/– 258 days). Results No bleeding events were reported in the late follow up. The low–INR regimen did not affect the thromboembolism rates, since no stroke or transient ischemic attack were reported post–operatively at each time point. No in–hospital or late deaths were reported among the 108 subjects analyzed. In the early period (<30 days), three reinterventions occurred: two because of postoperative bleeding requiring thoracotomy and one due to pericardial effusion. In the late postoperative period two reinterventions with device explant occurred (one for non–structural valve dysfunction and one for endocarditis (1.2%). Conclusion The results of the SURE–AVr Registry demonstrated that the proposed Lower–INR Target is safe and feasible after Bicarbon aortic mechanical valve replacement. The low–intensity anticoagulation strategy is associated with a low risk of hemorrhagic events without any increase of thromboembolic complications.

Surgical outcomes of pulmonary valve infective endocarditis: A US population-based analysis

BackgroundPulmonary valve infective endocarditis (PVIE) represents a rare subset of right-sided IE. This study aimed to evaluate the population-level surgical outcomes of PVIE in the United States. MethodsWe performed a retrospective observational study using the 2002–2017 National Inpatient Sample database. We included hospitalizations with both IE and PV interventions. We excluded Tetralogy of Fallot, congenital PV malformation, and those who underwent the Ross procedure. The primary outcome was in-hospital mortality. The secondary outcomes included major complications and length of hospital stay. ResultsWe identified 677 PVIE hospitalizations that underwent surgical treatment, accounting for 0.06% of all IE hospitalizations. The mean age was 35.2 ± 1.7 years; 60.0% were White, 30.3% were women, and 11.4% were intravenous drug users. Most were treated in large-sized (70.1%) urban teaching (88.8%) hospitals. Close to 30% of patients received at least one concomitant valve procedure. The in-hospital mortality was 5.5% for the entire cohort, and the median length of stay was 16 days. Major complications included complete heart block (8.7%), acute kidney injury (8.1%), and stroke (1.3%). The differences in mortality and complications rate comparing PV repair and replacement were not statistically significant. PV repair was associated with a longer length of hospital stay compared to PV replacement (median: 25 vs. 16 days, p = 0.03). ConclusionsThis study defines the population-level in-hospital outcomes after surgical intervention of PVIE. Surgically treated PVIE patients are associated with relatively low mortality and morbidities. The outcomes between PV replacement and repair are similar.

Bilateral mini-thoracotomy for combined minimally invasive direct coronary artery bypass and mitral valve repair.

Consistent evidence recognizes minimally invasive valve surgery as the top-tier surgical approach for heart valve pathology. Conversely, the overall adoption of minimally invasive coronary surgery remains low. Notwithstanding, excellent clinical outcomes have been recently reported, further consolidating a technique that addresses major concerns associated with the traditional approach for the most frequently performed cardiac operation, including sternal dehiscence (i.e sternal sparing) and stroke (i.e. no-touch aorta), but that also guarantees a reduced resort to blood transfusions, diminished pain and faster recovery. More to the point, the suitability of minimally invasive strategies for combined coronary and valve procedures remains debateable. Almost no reports of such combined procedures are available in literature and the very few published experiences appear scarce and heterogeneous about the surgical access (i.e. single versus bilateral mini-thoracotomy). However, bilateral mini-thoracotomy has been proposed as a feasible and safe strategy for different cardiac operations like surgical ablation and left ventricular assist device implantation, but also for isolated multivessel minimally invasive coronary surgery. Here, we describe the feasibility of combined minimally invasive mitral valve and coronary surgery performed through bilateral mini-thoracotomy and we report outcomes of our initial series of 3 cases.

Effect of glutamate infusion on NT-proBNP after coronary artery bypass grafting in high-risk patients (GLUTAMICS II): A randomized controlled trial.

BackgroundAnimal and human data suggest that glutamate can enhance recovery of myocardial metabolism and function after ischemia. N-terminal pro-brain natriuretic peptide (NT-proBNP) reflects myocardial dysfunction after coronary artery bypass surgery (CABG). We investigated whether glutamate infusion can reduce rises of NT-proBNP in moderate- to high-risk patients after CABG.Methods and findingsA prospective, randomized, double-blind study enrolled patients from November 15, 2015 to September 30, 2020, with a 30-day follow-up at 4 academic cardiac surgery centers in Sweden. Patients underwent CABG ± valve procedure and had left ventricular ejection fraction ≤0.30 or EuroSCORE II ≥3.0. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h started 10 to 20 minutes before releasing the aortic cross-clamp, then continued for another 150 minutes. Patients, staff, and investigators were blinded to the treatment. The primary endpoint was the difference between preoperative and day-3 postoperative NT-proBNP levels. Analysis was intention to treat.We studied 303 patients (age 74 ± 7 years; females 26%, diabetes 47%), 148 receiving glutamate group and 155 controls. There was no significant difference in the primary endpoint associated with glutamate administration (5,390 ± 5,396 ng/L versus 6,452 ± 5,215 ng/L; p = 0.086). One patient died ≤30 days in the glutamate group compared to 6 controls (0.7% versus 3.9%; p = 0.12). No adverse events linked to glutamate were observed.A significant interaction between glutamate and diabetes was found (p = 0.03). Among patients without diabetes the primary endpoint (mean 4,503 ± 4,846 ng/L versus 6,824 ± 5,671 ng/L; p = 0.007), and the incidence of acute kidney injury (11% versus 29%; p = 0.005) was reduced in the glutamate group. These associations remained significant after adjusting for differences in baseline data.The main limitations of the study are: (i) it relies on a surrogate marker for heart failure; and (ii) the proportion of patients with diabetes had almost doubled compared to the cohort used for the sample size estimation.ConclusionsInfusion of glutamate did not significantly reduce postoperative rises of NT-proBNP. Diverging results in patients with and without diabetes agree with previous observations and suggest that the concept of enhancing postischemic myocardial recovery with glutamate merits further evaluation.Trial registrationClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT02592824.European Union Drug Regulating Authorities Clinical Trials Database (Eudra CT number 2011-006241-15).

E-38 | Time Trends, Disparities, Mortality, and Cost of Tricuspid and Pulmonary Valve Procedures Among Malignant Carcinoid Tumors: Machine Learning and Propensity Score Case-control Analysis of Over 100 Million Hospitalizations and Three Years

E-38 | Time Trends, Disparities, Mortality, and Cost of Tricuspid and Pulmonary Valve Procedures Among Malignant Carcinoid Tumors: Machine Learning and Propensity Score Case-control Analysis of Over 100 Million Hospitalizations and Three Years

Appropriateness criteria for the use of cardiac computed tomography, SIC-SIRM part 2: acute chest pain evaluation; stent and coronary artery bypass graft patency evaluation; planning of coronary revascularization and transcatheter valve procedures; cardiomyopathies, electrophysiological applications, cardiac masses, cardio-oncology and pericardial diseases evaluation.

In the past 20 years, cardiac computed tomography (CCT) has become a pivotal technique for the noninvasive diagnostic workup of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Randomized clinical trials documented the value of CCT in increasing the cost-effectiveness of the management of patients with acute chest pain presenting in the emergency department, also during the pandemic. Beyond the evaluation of stents and surgical graft patency, the anatomical and functional coronary imaging have the potential to guide treatment decision-making and planning for complex left main and three-vessel coronary disease. Furthermore, there has been an increasing demand to use CCT for preinterventional planning in minimally invasive procedures, such as transcatheter valve implantation and mitral valve repair. Yet, the use of CCT as a roadmap for tailored electrophysiological procedures has gained increasing importance to assure maximum success. In the meantime, innovations and advanced postprocessing tools have generated new potential applications of CCT from the simple coronary anatomy to the complete assessment of structural, functional and pathophysiological biomarkers of cardiac disease. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), represents the second of two consensus documents collecting the expert opinion of cardiologists and radiologists about current appropriate use of CCT.

Multi-View 3D Transesophageal Echocardiography Registration and Volume Compounding for Mitral Valve Procedure Planning

Three-dimensional ultrasound mosaicing can increase image quality and expand the field of view. However, limited work has been done applying these compounded approaches for cardiac procedures focused on the mitral valve. For procedures targeting the mitral valve, transesophageal echocardiography (TEE) is the primary imaging modality used as it provides clear 3D images of the valve and surrounding tissues. However, TEE suffers from image artefacts and signal dropout, particularly for structures lying below the valve, including chordae tendineae, making it necessary to acquire alternative echo views to visualize these structures. Due to the limited field of view obtainable, the entire ventricle cannot be directly visualized in sufficient detail from a single image acquisition in 3D. We propose applying an image compounding technique to TEE volumes acquired from a mid-esophageal position and several transgastric positions in order to reconstruct a high-detail volume of the mitral valve and sub-valvular structures. This compounding technique utilizes both fully and semi-simultaneous group-wise registration to align the multiple 3D volumes, followed by a weighted intensity compounding step based on the monogenic signal. This compounding technique is validated using images acquired from two excised porcine mitral valve units and three patient data sets. We demonstrate that this compounding technique accurately captures the physical structures present, including the mitral valve, chordae tendineae and papillary muscles. The chordae length measurement error between the compounded ultrasound and ground-truth CT for two porcine valves is reported as 0.7 ± 0.6 mm and 0.6 ± 0.6 mm.

Concurrent valvular procedures during left ventricular assist device implantation and outcomes: A comprehensive analysis of the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 trial portfolio

BackgroundCorrection of valvular disease is often undertaken during left ventricular assist device (LVAD) implantation with uncertain benefit. We analyzed clinical outcomes with HeartMate 3 (HM3; Abbott) LVAD implantation in those with various concurrent valve procedures (HM3+VP) with those with an isolated LVAD implant (HM3 alone). MethodsThe study included 2200 patients with HM3 implanted within the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3) trial portfolio who underwent 820 concurrent procedures among which 466 (21.8%) were HM3+VP. VPs included 101 aortic, 61 mitral, 163 tricuspid; 85 patients had multiple VPs. Perioperative complications, major adverse events, and survival were analyzed. ResultsPatients who underwent HM3+VP had higher-acuity Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (1-2: 41% vs 31%) compared with no VPs (P < .05). The cardiopulmonary bypass time (124 vs 76 minutes; P < .0001) and hospital length of stay (20 vs 18 days; P < .0001) were longer in HM3+VP. A higher incidence of stroke (4.9% vs 2.4%), bleeding (33.9% vs 23.8%), and right heart failure (41.5% vs 29.6%) was noted in HM3+VP at 0 to 30 days (P < .01), with no difference in 30-day mortality (3.9% vs 3.3%) or 2-year survival (81.7% vs 80.8%). Analysis of individual VP showed no differences in survival compared to HM3 alone. No differences were noted among patients with either significant mitral (moderate or worse) or tricuspid (moderate or worse) regurgitation with or without corrective surgery. ConclusionsConcurrent VPs, commonly performed during LVAD implantation, are associated with increased morbidity during the index hospitalization, with no effect on short- and long-term survival. There is sufficient equipoise to consider a randomized trial on the benefit of commonly performed VPs (such as mitral or tricuspid regurgitation correction), during LVAD implantation.

Redo surgery for noninfective isolated mitral valve disease: Initial outcome and further follow-up compared to primary surgery.

Isolated redo-mitral valve replacement(iMVR) is underreported and often mixed up with endocarditis in the present literature. The present study compares first with redo iMVR in noninfective mitral disease. A total of 3821 mitral valve procedures were analyzed. The study was restricted to isolated and noninfective mitral valve replacements done by sternotomy. Finally, 402 patients are included, consisting of 102 redo- and 300 first surgeries. The mean patient's age was 65.9 ± 10.4 years; the mean EuroSCORE II was 3.0 ± 2.2%. Median follow-up was 221 days, ranging up to 9.9 years with a total of 367 patient-years. Redo's had higher EuroSCORE II (5.1 ± 2.9% vs. 2.3 ± 1.4%; p < .01), more atrial fibrillation (31.1% vs. 46.1%;p = .01), chronic obstructive pulmonary disease (7.3% vs. 17.6%;p = .05), coronary artery disease (7.3% vs. 17.6%;p = .03) and more frequently reduced ejection fraction < 30% (3.0% vs.11.8%;p = .02). Main outcomes showed comparable 30-days mortality (first: 4.1%, redo: 6.9%; p = .813). Postoperative morbidity of the redo's was associated with increased postoperative bleeding (p < .01) resulting in increased transfusions of packed red blood cells and fresh frozen plasma (each p < .01), more re-explorations (p < .01) and longer primary intensive care unitstay (p < .01). Postoperative occurrence of stroke, respiratory or renal failure, and myocardial infarction as well as hospital stay differed not significantly. Estimated 5-years survival was 65.5 ± 12.3% for all patients with no significant differences between the groups. Multivariate logistic regression respiratory failure as relevant for hospital (odds ratio [OR]: 12.3 [1.1-158]; p = .029) and stroke (OR: 4.8 [1.1-12.3]; p = .021) as relevant for long-term mortality. iMVR fornoninfective reasons is infrequent and rare. Compared to primary surgery, redo's suffer mainly from bleeding-associated morbidity. This does not translate into prolonged hospital stay or inferior immediate or long-term outcomes. Redo mitral valve replacement can be performed at no significantly increased surgical risk compared with first surgery and the results are particularly not limited by the surgery itself.

The impact of medical insurance reimbursement on postoperative inflammation reaction in distinct cardiac surgery from a single center

BackgroundEvidences shows that socioeconomic status is reversely associated with the risk of morbidity and mortality for people with cardiovascular disease via pro-inflammation mechanism, but the population profile is not deeply defined on. We aimed to investigate the impact of medical insurance coverage on postoperative systemic inflammatory reaction in two kinds of disease populations undergoing distinct cardiac procedures.MethodsA total of 515 patients receiving open mitral valve procedure with high-total expense from May 2013 through May 2021 in Sichuan Provincial People’s Hospital were retrospectively collected and stratified according to medical insurance reimbursement: low coverage with high out-pocket (< 30%), medium coverage (≤ 60%, but ≥ 30%), and high coverage (> 60%). Another 118 cases undergoing atrium septum defect (ASD) or patent foramen ovale (PFO) occlusion and taking on consistent low-total expense and low-coverage (< 30%) were also classified according to their insured conditions. The postoperative systemic inflammatory response indexes were high sensitivity C-reactive protein (hs-CRP) and the neutrophil–lymphocyte ratio (NLR).ResultsLow insurance reimbursement population undergoing open mitral valve procedure had a higher level of hs-CRP and NLR but not troponin I protein or lactate within 48 h postoperatively, and higher thoracic drainage, longer ventilation use and stay in intensive care unit. No significant difference in inflammatory indexes existed among diverse medical insurance coverage in population undergoing ASD/PFO occlusion. ConclusionsHigher inflammatory reaction and weaker clinical recovery was associated with lower insurance coverage population undergoing open mitral valve procedure but not ASD/PFO interventional occlusion procedure.

Medium-term outcomes from mitral valve surgery for rheumatic heart disease in young adults in Aotearoa New Zealand: a cohort study.

Rheumatic heart disease (RHD) remains an important cause of morbidity and mortality in New Zealand. Factors associated with the choice of surgical treatment for advanced RHD in young adults are poorly understood. We sought to review our local experience with the surgical management of young adults with rheumatic mitral valvular disease. From 2003 to 2016, all patients aged 15-24 years undergoing mitral valve surgery for rheumatic disease at Auckland City Hospital, New Zealand were retrospectively reviewed. During the 13-year study period, 73 young adults underwent mitral surgery; 85% were Maori or Pacific Islanders. Mitral repair was performed in 32 patients and replacement in 41 patients. Isolated mitral valve surgery was performed in 36%, double valve procedures in 47%, and triple valve procedures in 17% of patients. The 30-day mortality rate and stroke rate were 1.4% and 2.7% respectively. The medium-term mortality rate was 11.9% across a mean follow-up of 6 years (6.9% in the repair group, 15.8% in the replacement group, p=0.25). There were increased bleeding complications (p=0.04) in patients with mechanical mitral valve replacement. For patients on warfarin, across medium-term follow-up, the INR was in the therapeutic range only 23% of the time. Most young adults in New Zealand with severe RHD requiring surgery are of indigenous Maori or Pacific Island ethnicity. There is a trend towards improved survival with mitral repair. There is a significant tendency towards increased bleeding complications in patients on warfarin for mechanical mitral replacement. Warfarin compliance is poor.

Concomitant Valvular Procedures During LVAD Implantation and Outcomes: An Analysis of the MOMENTUM 3 Trial Portfolio

<h3>Purpose</h3> Correction of valvular pathology is often undertaken in patients undergoing LVAD implantation but impact on outcomes is uncertain. We compared clinical outcomes with HeartMate 3 (HM3) LVAD implantation in those with concurrent valve procedures (VP) to those with an isolated LVAD implant within the MOMENTUM3 trial portfolio, including the Pivotal Trial (n=515, NCT02224755) and Continued Access Protocol/ CAP (n=1685, NCT02892955). <h3>Methods</h3> The study included 2200 HM3 implanted patients. Among 820 concurrent procedures (including VP, CABG, RVAD, LAA closure), 466 (21.8%) were VPs (HM3+VP), including 81 aortic, 61 mitral, 163 tricuspid, and 85 patients with multiple VPs. Short and Long-term outcomes including peri-operative complications and healthcare resource use, major adverse events and survival were analyzed. <h3>Results</h3> Patients undergoing HM3+VP were older (63[54-70] vs. 62[52-68] yrs), with a sicker INTERMACS profile (1-2:41% vs.31%) and higher central venous pressure (11[8-16] vs. 9[6-14] mmHg) compared to HM3 alone (all p<0.05). The cardiopulmonary bypass time (124[97-158] vs.76[59-96] mins); ICU (8.5 [5-16] vs. 7 [5-13]) and hospital length of stay (20 [15-30] vs. 18 [14-24] days) were longer in HM3+VP (all p<0.0001). A significantly higher incidence of stroke (4.9% vs. 2.4%), bleeding (33.9% vs. 23.8%) and right heart failure (41.5% vs. 29.6%) was noted in HM3+VP for 0-30 days post-implant (all p<0.01), but 30-day survival was similar between groups (96.7% vs. 96.1%). There was no difference in 2-year survival in HM3+VP vs HM3 alone patients (HR[95%CI]:0.93 [0.71-1.21];p=0.60). Analysis of individual VPs showed no significant differences in survival compared to HM3 alone (Figure). <h3>Conclusion</h3> Concurrent VPs are commonly performed during LVAD implantation, are associated with increased morbidity during the index hospitalization, but short and long-term survival are not impacted adversely when compared with those that undergo an isolated LVAD procedure.

Use of Extracorporeal Membrane Oxygenation Support in Adult Aortic Surgery

<h3>Purpose</h3> Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used for post-cardiotomy shock (PCS). Its application to post-aortic surgical patients is challenging. We report our experience of VA-ECMO support for PCS following aortic surgery. <h3>Methods</h3> A total of 126 adult patients required VA-ECMO for PCS from Jan 2007 to Feb 2017. Of this group, 27 patients underwent aortic surgery (Group AO). Outcomes were examined, as well as risk factors for mortality, and this group was compared to those requiring ECMO for PCS following coronary artery bypass graft (CABG) and/or valve procedures (Group CV, n=65). <h3>Results</h3> Fifteen patients had acute type A aortic dissection and 6 had ascending and/or root aneurysm. Root replacement was performed in 13 patients, ascending in 11, and arch replacement 2, with concomitant procedures in 17 patients. Mean cardiopulmonary bypass time was 280±125 minutes and mean aortic cross-clamp time was 153±79 minutes. In-hospital mortality was 51.8%. Significant bleeding, new hemodialysis requirement, and neurological complications occurred in 59%, 37%, and 11% of patients, respectively. Risk factors for in-hospital mortality in logistic regression analysis included coronary artery disease (OR 7.3, 95% CI 1.3-60.3, p=0.034), aortic cross-clamp time >150 minutes (OR 6.0, 95% CI 1.2-41.1, p=0.048), lactate > 6 mg/dL at 24 hours post-ECMO initiation (OR 12.0, 95% CI 1.6-255.6, p=0.037) and bleeding complication (OR 5.9, 95% CI 1.2-37, p=0.041). Compared to Group CV, Group AO had significantly longer bypass and cross-clamp times, and a greater proportion of patients underwent ECMO cannulation via the axillary artery. In-hospital mortality was not significantly different (51.8% vs. 63.1%, p=0.356). <h3>Conclusion</h3> ECMO support for aortic surgical patients provides survival comparable to that for CABG and/or valve patients.

Practicing functional nasal surgery in the non-urban setting: experience from a single center

Nasal airway obstruction is a prevalent chief complaint in the contemporary facial plastic surgery practice. Studies report an asymmetric distribution of plastic surgeons across the United States with a disproportionately high concentration of surgeons practicing in urban areas. The lack of elective specialist care creates unique challenges for these patients who may need to travel and dedicate time to reach a nasal surgery expert. We conducted a retrospective chart review to report our experience from practicing functional nasal surgery in such a non-urban setting in the United States. A total of 103 patients underwent functional nasal surgery (FNS) between May 2015 and August 2021 including septoplasty, inferior turbinate reduction, septorhinoplasty and nasal valve procedures. We present the epidemiological characteristics, surgical techniques used and postoperative complications and illuminate the unique characteristics of practicing FNS in the non-urban setting.