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BACKGROUND: Alpha-gal syndrome is an allergic condition in which individuals develop an immune-mediated hypersensitivity response when consuming red meat and its derived products. Its diagnosis is important in individuals undergoing cardiac surgery, as patients frequently require large doses of unfractionated heparin or the insertion of surgical implants, both of which are porcine or bovine in origin. There are currently no guidelines for heparin administration in alpha-gal patients, with even less knowledge regarding the long-term clinical implications of these patients after receiving bioprosthetic valve replacements or other prostheses. CASE PRESENTATION: We present the case of a 31-year-old male who underwent cardiac surgery in the setting of alpha-gal syndrome for a large atrial septal defect (ASD) and mitral valve prolapse (MVP). The patient continues to do well one year after undergoing a mitral valve repair, tricuspid valve repair and an ASD closure using bovine pericardium. He sustained no adverse reaction to the use of heparin products or the presence of a bovine pericardial patch. This rare case was managed by a multidisciplinary team consisting of cardiothoracic surgery, cardiac anesthesiology, and allergy/immunology that led to an optimal outcome despite the patient's pertinent allergic history. CONCLUSIONS: This case highlights that the use of bovine pericardium and porcine heparin to close septal defects in patients with milder forms of alpha-gal allergy can be considered if other options are not available. Further studies are warranted to investigate the long-term outcomes of such potential alpha-gal containing prostheses and heparin exposure and establish the optimal decision making algorithm and prophylactic regimen.
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Hipersensibilidad a los Alimentos , Defectos del Tabique Interatrial , Masculino , Humanos , Bovinos , Animales , Porcinos , Adulto , Heparina/uso terapéutico , Pericardio , Defectos del Tabique Interatrial/cirugía , ContraindicacionesRESUMEN
We report our technique for the surgical revascularization of symptomatic severe in-stent restenosis of a "full metal jacket" (≥60 mm overlapping stents) of the left anterior descending coronary artery without suitable distal targets: on-pump cardioplegic-arrest stent removal (stentectomy) with endarterectomy and skeletonized left internal mammary artery onlay patch reconstruction. We also describe our follow-up protocol, including antiplatelet/anticoagulation and angiography. With proper patient selection, multidisciplinary collaboration, and surgical expertise, this advanced coronary procedure can be beneficial to a growing population of patients otherwise deemed to be untreatable.
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Enfermedad de la Arteria Coronaria , Reestenosis Coronaria , Angiografía Coronaria , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/cirugía , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Endarterectomía , Humanos , Stents , Resultado del TratamientoRESUMEN
The convergent procedure is a newly developed hybrid ablation procedure that involves extensive epicardial ablation of the posterior left atrial wall followed by endocardial mapping and addition of pulmonary vein isolation. It is a team-based approach that provides a promising option for patients with persistent and permanent atrial fibrillation. In this manuscript, we present a detailed description of the surgical component of this procedure and include potential pitfalls based on our experience in performing it.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Endocardio , Humanos , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/cirugía , Resultado del TratamientoRESUMEN
IMPORTANCE: As the Coronavirus disease 2019 (COVID-19) pandemic accelerates, our hospitals have become overwhelmed. OBJECTIVE: To describe detection of COVID-19 in asymptomatic hospitalized individuals awaiting advanced therapies for HF and the management of complications of COVID-19. DESIGN: We present a unique case report of hospital-acquired COVID-19 in a patient on temporary mechanical circulatory support. MAIN OUTCOME: Despite intensive care and monitoring, he developed rapid progression of hypoxic respiratory failure which led to his death. CONCLUSION: This case highlights various considerations for a patient with temporary MCS. It illustrates the high risk for development of COVID-19 for vulnerable hospitalized patients.
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Infecciones por Coronavirus , Infección Hospitalaria , Insuficiencia Cardíaca , Corazón Auxiliar , Pandemias , Neumonía Viral , Infecciones Asintomáticas , Betacoronavirus , COVID-19 , Deterioro Clínico , Infecciones por Coronavirus/complicaciones , Infecciones por Coronavirus/diagnóstico , Infección Hospitalaria/complicaciones , Infección Hospitalaria/diagnóstico , Resultado Fatal , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/terapia , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Neumonía Viral/complicaciones , Neumonía Viral/diagnóstico , SARS-CoV-2RESUMEN
OBJECTIVE: The study objective was to describe the clinical outcomes of elderly patients undergoing ascending aortic surgery. METHODS: Patients aged 70 years or older who underwent ascending aortic surgery between January 2002 and December 2013 were examined. Of 415 included patients, 285 were elderly patients (age 70-79 years) and 130 were very elderly (age ≥80 years). Logistic regression and Cox proportional hazards models were used to evaluate operative mortality and long-term survival, respectively. RESULTS: Surgical indications included aortic aneurysm (63.1%), calcified aorta with need for other cardiac procedure (26.4%), and type A dissection (10.5%). Compared with elderly patients, the very elderly patients had a higher burden of comorbidities and operative mortality (13% vs 7%, P < .04). The very elderly patients were also more likely to be discharged to a rehabilitation facility than home (P < .001). However, risk-adjusted operative mortality and 30-day readmissions rates were similar (P > .05). Kaplan-Meier estimates of survival at 1 and 5 years were 85.6% and 72.6% for elderly patients versus 79.2% and 57.1% for the very elderly patients. Age was a strong risk variable for late mortality in the unadjusted and adjusted analyses. CONCLUSIONS: After adjusting for these comorbidities, the cause of aortic disease, and the type of procedure, age was not an independent predictor of operative mortality, but was strongly associated with reduced late survival. Thus, advanced age alone should not be an absolute contraindication for ascending aortic surgery.
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Aorta/cirugía , Factores de Edad , Anciano , Anciano de 80 o más Años , Disección Aórtica/mortalidad , Disección Aórtica/cirugía , Aneurisma de la Aorta/mortalidad , Aneurisma de la Aorta/cirugía , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
INTRODUCTION: Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG). METHODS: We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression. RESULTS: Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17]). CONCLUSIONS: Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG.
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Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/mortalidad , Vasos Coronarios/cirugía , Femenino , Humanos , Masculino , Arterias Mamarias/trasplante , Persona de Mediana Edad , Estudios Retrospectivos , Riesgo , Tasa de Supervivencia , Factores de TiempoRESUMEN
BACKGROUND: We investigated whether extended arterial grafting with three or more arterial grafts in patients with a left internal thoracic artery to left anterior descending artery graft improves survival in coronary artery bypass graft surgery patients and whether its effects will depend on the extent of coronary artery disease; specifically three-vessel disease (3VD) versus two-vessel disease (2VD). METHODS: Fifteen-year mortality was analyzed in 11,931 patients with multivessel disease and primary isolated left internal thoracic artery to left anterior descending artery coronary artery bypass graft surgery with 2 or more grafts. Patients were aged 64.3 ± 10.5 years; 3,484 (29.2%) were women; 2,532 (21.2%) had 2VD and 9,399 (78.8%) had 3VD. Patients were grouped into one single-artery group (n = 6,782, 56.9%; reference group), and two multiple artery groups: two arteries (n = 3,678, 30.8%) and three arteries (n = 1,471, 12.3%). Long-term survival was compared by Kaplan-Meier estimates. Risk-adjusted mortality hazard ratio (HR) with 95% confidence interval (CI) were derived by covariate adjusted Cox regression to quantify multiple artery effects versus one artery in the overall cohort and separately among patients with 2VD and 3VD. RESULTS: Radial artery (94%) and right internal thoracic artery (6%) conduits were used for additional arterial grafts. For the entire multivessel cohort, increasing number of arterial grafts was associated with incrementally improved 15-year survival (two arteries HR 0.85, 95% CI: 0.78 to 0.92; three arteries HR 0.75, 95% CI: 0.65 to 0.85). The three arteries versus two arteries comparison was consistent, even if not significant (HR 0.89, 95% CI: 0.77 to 1.03). The benefits derived from additional arterial grafts were more pronounced in case of 3VD (two arteries HR 0.84 95% CI: 0.76 to 0.92; three arteries HR 0.73, 95% CI: 0.63 to 0.84), without survival benefit with 2VD. CONCLUSIONS: Our results support the use of extended arterial grafting to maximize long-term coronary artery bypass graft surgery patient survival, especially for 3VD patients.
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Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/cirugía , Predicción , Arterias Mamarias/trasplante , Arteria Radial/trasplante , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Vasos Coronarios/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: During cardiac surgery with cardiopulmonary bypass, delivery of cardioplegia solution to achieve electromechanical cardiac quiescence is obligatory. The addition of lidocaine to cardioplegia has advantages, although its consequences at a molecular level remain unclear. We performed whole-genome RNA sequencing of the human left ventricular (LV) myocardium to elucidate the differences between whole-blood (WB) cardioplegia with and without addition of lidocaine (LC) on gene expression. METHODS: We prospectively enrolled 130 patients undergoing aortic valve replacement surgery. Patients received high-potassium blood cardioplegia either with (n = 37) or without (n = 93) lidocaine. The LV apex was biopsied at baseline, and after an average of 74 minutes of cold cardioplegic arrest. We performed differential gene expression analysis for 18,258 genes between these 2 groups. Clinical and demographic variables were adjusted in the model. Gene ontology (GO) and network enrichment analysis of the retained genes were performed using g:Profiler and Cytoscape. RESULTS: A total of 1,298 genes were differentially expressed between cardioplegic treatments. Compared with the WB group, genes upregulated in the LC group were identified by network enrichment to play a protective role in ischemic injury by inhibiting apoptosis, increasing transferrin endocytosis, and increasing cell viability. Downregulated genes in the LC group were identified to play a role in inflammatory diseases, oxygen transport, and neutrophil aggregation. CONCLUSIONS: The addition of lidocaine to cardioplegia had pronounced effects on a molecular level with genes responsible for decreased inflammation, reduced intracellular calcium binding, enhanced antiapoptotic protection, augmented oxygen accessibility through transferrins, and increased cell viability showing measurable differences.
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Válvula Aórtica/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Paro Cardíaco Inducido/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Lidocaína/administración & dosificación , Centros Médicos Académicos , Factores de Edad , Anciano , Anciano de 80 o más Años , Válvula Aórtica/fisiopatología , Procedimientos Quirúrgicos Cardíacos/mortalidad , Soluciones Cardiopléjicas/administración & dosificación , Puente Cardiopulmonar/métodos , Puente Cardiopulmonar/mortalidad , Estudios de Cohortes , Regulación de la Expresión Génica , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Biología Molecular , Valores de Referencia , Estudios Retrospectivos , Medición de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Multiarterial coronary grafting with two arterial grafts leads to improved survival compared with conventional single artery based on left internal thoracic artery to left anterior descending artery and saphenous vein grafts. We investigated whether extending arterial grafting to three or more arterial grafts further improves survival, and whether such a benefit is modified by diabetes mellitus. METHODS: We analyzed 15-year coronary artery bypass graft surgery mortality data in 11,931 patients (age 64.3 ± 10.5 years; 3,484 women [29.2%]; 4,377 [36.7%] with diabetes mellitus) derived from three US institutions (1994 to 2011). All underwent primary isolated left internal thoracic artery to left anterior descending artery grafting with at least two grafts: one artery (n = 6,782; 56.9%); two arteries (n = 3,678; 30.8%); or three or more arteries (n = 1,471; 12.3%). Long-term survival was estimated by Kaplan-Meier methods. Propensity score matching and comprehensive covariate adjustment (Cox regression) were used to derive long-term risk-adjusted hazard ratio (HR) with 95% confidence interval (CI) for increasing number of arterial grafts in the overall cohort and for diabetes and no-diabetes cohorts. RESULTS: Radial artery (94%) and right internal thoracic artery (6%) were used as additional arterial grafts. Multivariate analysis in all patients showed that diabetes was associated with decreased survival (HR 1.43, 95% CI: 1.34 to 53), whereas increasing number of arterial grafts was associated with decreased mortality (one artery HR 1.0 [reference]; two arteries HR 0.87, 95% CI: 0.80 to 0.95; and three arteries HR 0.83, 95% CI: 0.72 to 0.95). Pairwise comparisons also showed an incremental benefit of additional arterial grafts: two arteries versus one artery, HR 0.89 (95% CI: 0.80 to 0.98); and three arteries versus one artery, HR 0.80 (95% CI: 0.68 to 0.94). A three-artery versus two-artery survival advantage trend was also noted, but was not significant in either the overall study cohort (HR 0.90, 95% CI: 0.75 to 1.07), the diabetes cohort (HR 0.79, 95% CI: 0.60 to 1.03), or the no-diabetes cohort (HR 01.00, 95% CI: 0.79 to 1.26). Among diabetes patients, the survival advantage of two arteries versus one artery was modest (HR 0.96, 95% CI: 0.72 to 1.11), whereas it was significant for three arteries versus one artery (HR 0.74, 95% CI: 0.58 to 0.96). Analyses of propensity matched subcohorts were also consistent. CONCLUSIONS: Increasing number of arterial grafts improves long-term survival and supports extended use of arterial grafts in coronary artery bypass graft surgery, irrespective of diabetes status.
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Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Diabetes Mellitus/diagnóstico , Arterias Mamarias/trasplante , Arteria Radial/trasplante , Vena Safena/trasplante , Anciano , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/mortalidad , Bases de Datos Factuales , Diabetes Mellitus/mortalidad , Diabetes Mellitus/cirugía , Femenino , Supervivencia de Injerto , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Pronóstico , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
Surgical aortic valve replacement (SAVR) in patients with porcelain aorta is considered a high-risk procedure. Hence, transcatheter aortic valve implantation (TAVI) is emerging as the intervention of choice. However, there is a paucity of data directly comparing TAVI with SAVR in patients with porcelain aorta. We compared outcomes of TAVI versus SAVR in high-risk patients with porcelain between March 2012 and June 2015. The TAVI group included 54 patients, whereas 130 SAVR patients with porcelain aorta were identified (operated on between 2004 and 2015). Both groups were matched 1:1 based on the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score with a 0.5% a priori caliper, resulting in 52 matched pairs. The mean STS-PROM was 7.3 ± 3.9 for both groups (p = 0.98), whereas mean age was 77.5 years for TAVI and 78.8 years for SAVR (p = 0.46). Compared with SAVR, TAVI patients had lower operative mortality (3.8% vs 17.3%; p = 0.052), significantly shorter median intensive care unit (40 vs 107 hours; p < 0.001) and hospital (5 vs. 7 days; p < 0.001) length of stay (LOS), but similar postoperative stroke rates (7.7% vs 11.5%; p = 0.74). One-year unadjusted survival was 81.7% (95% confidence interval [CI]: 69.8% to 93.5%) in the TAVI group versus 71.2% (95% CI: 61.0% to 85.1%) in the SAVR group, p = 0.093. Cox proportional hazard modeling identified preoperative chronic kidney disease (hazard ratio: 2.63 [95% CI: 1.03 to 6.70]; p = 0.043) and SAVR (hazard ratio: 2.641 [95% CI: 1.07 to 6.51]; p = 0.035) as significant predictors for decreased survival. Overall, TAVI was associated with reduced operative mortality, increased survival, and shorter intensive care unit and hospital length of stay compared with SAVR in patients with porcelain aorta. This study demonstrates that TAVI is a safe intervention in this high-risk population.
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Aorta/anomalías , Estenosis de la Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/patología , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: Bicuspid aortic valve (BAV) is the most common congenital valvular abnormality and frequently presents with accelerated calcific aortic valve disease, requiring aortic valve replacement (AVR) and thoracic aortic aneurysm and dissection. Supporting evidence for Association Guidelines of aortic dimensions for aortic resection is sparse. We sought to determine whether concurrent repair of dilated or aneurysmal aortic disease during AVR in patients with BAV substantially improves morbidity and mortality outcomes. METHODS: Mortality and reoperation outcomes of 1301 adults with BAV and dilated aorta undergoing AVR-only surgery were compared to patients undergoing AVR with aortic resection (AVR-AR) using Cox proportional hazards modelling and patient matching. RESULTS: Clinically important differences in patient characteristics, aortic valve function and aortic dimensions were identified between cohorts. Event rates were low, with rates of reoperation and death within 1 year of only 1.8% and 5.4%, respectively, and no aortic dissection observed during follow-up. There were no significant differences in reoperation or mortality outcomes between the AVR-only and AVR-AR cohorts. Age, aortic dimension or a combination thereof was not associated with better or worse outcomes after each AVR-AR compared with AVR. CONCLUSIONS: We conclude AVR-only and AVR-AR surgery have low morbidity and mortality and have utility over a wide range of age and aortic sizes. Our results do not provide support for the 45-mm aortic dimension recommended in the current guidelines for aortic resection while performing AVR or any other specific dimension.
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Válvula Aórtica/anomalías , Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta/cirugía , Enfermedad de la Válvula Aórtica Bicúspide , Femenino , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Valve-sparing aortic root replacement (VSARR) is an increasingly popular alternative to traditional aortic root replacement for aortic root aneurysm disease with a normal aortic valve. We evaluated the early and midterm outcomes of VSARR-reimplantation technique (VSARR-RT) done at a single institution over a decade. MATERIALS AND METHODS: We performed a retrospective study of all patients who underwent VSARR-RT between January 2004 and July 2014. RESULTS: A total of 85 patients underwent VSARR-RT. Median time to latest echocardiographic follow-up was 4 years (range: 15-72 months). Total observation time was 491 patient years. Mean age was 44.6 ± 14.3 years, and 13 (15%) were women. Thirty-nine (46%) patients had a connective tissue disorder and 6 (7%) had a bicuspid aortic valve. Thirty-three (39%) patients underwent concomitant procedures, including coronary artery bypass grafting (n = 9, 11%), mitral valve repair (n = 8, 9%), and aortic hemi-arch replacement (n = 7, 8%). There were no operative deaths or in-house mortality and no postoperative strokes. Kaplan-Meier analysis demonstrated survival of 99% (95% confidence interval [CI]: 97-100%) at 2 years and 98% (95% CI: 97-100%) at 8 years. Freedom from reoperation was 95.8% (95% CI: 91.2-100%) at 8 years. Freedom from endocarditis was 100% at 8 years. At the last echocardiographic follow-up, 95% of patients were free of severe aortic regurgitation (AR) and 82% free of moderate AR. Of the four patients who had severe AR, three underwent reoperations and received prosthetic valves and one is being clinically monitored. CONCLUSION: This study reports early and midterm outcomes after VSARR-RT at our institution, including those patients who underwent a VSARR-RT procedure combined with other procedures. Further follow-up remains necessary to determine long-term outcomes.
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BACKGROUND: The objective of this study was to investigate the association of the coronary SYNTAX score with the degree of atherosclerosis of the ascending aorta in patients who underwent coronary artery bypass grafting (CABG). METHODS: A total of 152 patients (mean age 65 years, 66% male) were analyzed who underwent isolated CABG with both SYNTAX score and the intraoperative 5-point scale grading of the severity of atherosclerosis in the ascending aorta available. The patient were stratified into low, intermediate, and high SYNTAX score groups [≤22 (n=36), 22-33 (n=42), and ≥33 (n=76)]. RESULTS: The mean SYNTAX score was 31±11. Patient demographics and comorbidity were comparable in each group. The prevalence of severe atherosclerosis (Grade ≥III) in the ascending aorta was 17.5% (n=27) in the whole population and was different in each group with higher prevalence in higher score groups (8.3% vs. 9.5% vs. 26.3%, P=0.018). After adjusting for age, sex and other relevant comorbidity, SYNTAX score remained a predictor of severe atherosclerosis [adjusted OR 1.63, 95% CI: 1.01-2.62, P=0.046 (per 10 point increase); adjusted OR 5.20, 95% CI: 1.15-23.5, P=0.032 (high vs. low score)]. CONCLUSIONS: SYNTAX score was associated with the severity of atherosclerosis in the ascending aorta. Patients with high scores have a 5 times higher chance of severe disease compared to patients with low scores and should warrant preoperative and intraoperative comprehensive assessment of the ascending aorta.
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BACKGROUND: Patient comorbidities play a pivotal role in the surgical outcomes of reoperative aortic valve replacement (re-AVR). Low left ventricular ejection fraction (LVEF) and renal insufficiency (Cr >2 mg/dL) are known independent surgical risk factors. Improved preoperative risk assessment can help determine the best therapeutic approach. We hypothesize that re-AVR patients with low LVEF and concomitant renal insufficiency have a prohibitive surgical risk and may benefit from transcatheter AVR (TAVR). METHODS: From January 2002 to March 2013, we reviewed 232 patients who underwent isolated re-AVR. Patients older than 80 years were excluded to adjust for unobserved frailty. We identified 37 patients with a ≤35% LVEF (low ejection fraction group-LEF) and 195 patients with >35% LVEF (High ejection fraction group-HEF). RESULTS: The mean age was 68.4±11.5 years and there were more females (86.5% versus 64.1%, P=0.007) in the LEF group. The prevalence of renal insufficiency was higher in LEF patients (27% versus 5.6%, P=0.001). Higher operative mortality (13.5% versus 3.1%, P=0.018) was observed in the LEF group. Stroke rates were similar in both groups (8.1% versus 4.1%, P=0.39). Unadjusted cumulative survival was significantly lower in LEF patients (6.6 years, 95% CI: 5.2-8.0, versus 9.7 years, 95% CI: 8.9-10.4, P=0.024). In patients without renal insufficiency, LEF and HEF had similar survival (8.3 years, 95% CI: 7.1-9.5, versus 9.9 years, 95% CI: 9.1-10.6, P=0.90). Contrarily, in patients with renal insufficiency, LEF led to a significantly lower survival (1.1 years, 95% CI: 0.1-2.0, versus 4.8 years, 95% CI: 2.2-7.3, P=0.050). Adjusted survival analysis revealed elevations in baseline creatinine (HR =4.28, P<0.001) and LEF (HR =5.33, P=0.041) as significant predictors of long-term survival, with a significant interaction between these comorbidities (HR =7.28, P<0.001). CONCLUSIONS: In re-AVR patients, low LVEF (≤35%) is associated with increased operative mortality. Concomitant renal insufficiency in these patients results in a prohibitively low cumulative survival. These reoperative surgical outcomes should warrant expanding the role of TAVR for reoperative patients with LEF and renal impairment.
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BACKGROUND: Isolated tricuspid valve (ITV) operations are infrequent and the decision to operate is controversial. We report a series of ITV operations to outline the current disease status requiring this uncommon procedure with an emphasis on the results of tricuspid valve repair (TVr) versus replacement (TVR). METHODS: Using our prospective cardiac surgery database, 57 patients who underwent ITV operations between 01/02-03/14 were identified. Median follow up time was 3.5 years [interquartile range (IQR), 0.8-6.7 years]. RESULTS: Fifty-seven patients underwent ITV surgery with a mean age of 54.4±14.9 yrs and 61% were women. Baseline characteristics were similar between patients who underwent TVr (n=18) or TVR (n=39). The etiologies of TV dysfunction were: ITV endocarditis 14/57 (25%), persistent TV regurgitation after left-sided valve surgery in 12/57 (21%), traumatic biopsies and iatrogenic injury from pacing leads in 11/57 (19%), orthotopic heart transplant 9/57 (16%), carcinoid syndrome 3/57 (5%), congenital 2/57 (5%) and idiopathic 5/57 (9%). Overall, 32/57 (56%) patients had prior heart surgery; of which 10/32 (31%) were TV procedures. Bioprosthetic prostheses were used in 34/39 (87%) patients. Of those who had repair, 11/18 (61%) had ring annuloplasty, 3/18 (17%) bicuspidization, and 3/18 (17%) De Vega annuloplasty and one had vegetectomy. Operative mortality was 5.1% (n=2) and 16.7% (n=3) for TVR and TVr groups, respectively (P=0.32), with an overall mortality rate of 8.6%. Postoperative complications included new onset renal failure in 6/39 (15%) of TVr and 2/18 (11%) of TVR (P=0.71) and there were no strokes. Overall survival rates and degree of residual RV dysfunction were similar for the two groups (both P=0.3). Five-year survival was 77% and 84% for TVr and TVR respectively (P=0.52). There was no difference in rates of recurrent tricuspid regurgitation for TVr and TVR (35.7% vs. 23.5%, respectively, P=0.4). CONCLUSIONS: ITV surgery is associated with improved but still relatively high operative mortality. Mid-term outcomes for TVr and TVR are similar with regards to postoperative complications, survival, and freedom from recurrent tricuspid regurgitation.
RESUMEN
BACKGROUND: Bioprosthetic aortic valve use has increased steadily according to The Society of Thoracic Surgeons (STS) database analyses. One of the momentums toward this trend is the future utilization of transcatheter valve-in-valve (TViV) techniques when bioprosthetic valves fail. We compared the results of reoperative TViV to surgical aortic valve replacement (SAVR) for degenerated bioprosthetic valves. METHODS: From January 2002 to January 2015, we identified 91 patients with degenerated bioprosthetic valves who underwent isolated AVR (SAVR n = 69, TViV n = 22). Patients with prior homografts or active endocarditis were excluded. The STS risk score was used to create 22 matched pairs of SAVR and TViV for comparison. RESULTS: Before matching, mean STS risk scores were 4.36 ± 3.1 and 7.54 ± 3.0 for SAVR and TViV, respectively (p = 0.001), but were 7.70 ± 3.4 and 7.54 ± 3.0, respectively (p = 0.360), after matching. Mean age was 74.5 ± 10.4 years for SAVR and 75.0 ± 9.6 years for TViV (p = 0.749). Operative mortality was 4.3% (1 of 22) in the SAVR group and zero for TViV (p = 1.00). Mean postoperative gradient was 13.5 ± 13.2 mm Hg for SAVR and 12.4 ± 6.2 mm Hg for TViV (p = 0.584). There was no coronary obstruction in either group, but 22% of TViV (5 of 22) had mild paravalvular leaks versus none in the SAVR group (p = 0.048). Postoperative stroke rate was 9% (2 of 22) for SAVR and zero for TViV (p = 0.488). The TViV group had shorter median length of stay (5 versus 11 days, p = 0.001). Actuarial survival at 3 years was 76.3% (95% confidence interval: 58.1 to 94.5) versus 78.7 (95% confidence interval: 56.2 to 100) for SAVR and TViV, respectively (p = 0.410). CONCLUSIONS: For degenerated bioprosthetic aortic valves, TViV has similar operative mortality, strokes rates, and survival as SAVR in this high-risk cohort. Therefore, TViV is a viable alternative to SAVR, although studies using registry data are needed to establish noninferiority.