Data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database were analyzed to identify trends in patient characteristics and outcomes of mitral valve operations in North America.
All ...patients with isolated primary mitral valve operations with or without tricuspid valve repair, surgical atrial fibrillation ablation, or atrial septal defect closure performed July 2011 to September 2016 were identified. A subgroup analysis assessed patients with degenerative leaflet prolapse (DLP).
Isolated primary mitral valve operations were performed on 87,214 patients at 1,125 centers, increasing by 24% between 2011 (n = 14,442) and 2016 (n = 17,907). The most common etiology was DLP (60.7%); 4.3% had functional mitral regurgitation. Preoperatively, 47.3% of patients had an ejection fraction less than 60% and 34.2% had atrial fibrillation. Overall mitral valve repair rate was 65.6%, declining from 67.1% (2011) to 63.2% (2016; p < 0.0001). Repair rates were related to etiology (DLP, 82.5%; rheumatic, 17.5%). Of the 29,970 mitral valve replacements, 16.2% were preceded by an attempted repair. Repair techniques included prosthetic annuloplasty (94.3%), leaflet resection (46.5%), and artificial cord implantation (22.7%). Bioprosthetic valves were implanted with increasing frequency (2011, 65.4%; 2016, 75.8%; p < 0.0001). Less-invasive operations were performed in 23.0% and concomitant tricuspid valve repair in 15.7%. Unadjusted operative mortality was 3.7% (replacements) and 1.1% (repairs).
Patients undergoing primary isolated mitral valve operations commonly have ventricular dysfunction, atrial fibrillation, and heart failure. Although contemporary outcomes are excellent, earlier guideline-directed referral and increased frequency and quality of repair may further improve results of mitral valve operations.
Objective We investigated the impact of preoperative pulmonary hypertension (PH) on early and late outcomes after mitral valve operation for mitral regurgitation. Methods Systolic pulmonary artery ...pressure (sPAP) was measured before operation in 873 consecutive patients who underwent mitral valve surgery for mitral regurgitation between January 2002 and January 2010. PH was classified as none (sPAP < 40 mm Hg), mild (40 ≤ sPAP < 50 mm Hg), moderate (50 ≤ sPAP < 60 mm Hg), or severe (sPAP ≥ 60 mm Hg). Results Increased preoperative sPAP was associated with greater left ventricular dysfunction and dilation, left atrial enlargement, more atrial fibrillation, and tricuspid regurgitation. Operative mortality was correlated with the degree of preoperative PH (2%, 3%, 8%, and 12% for none, mild, moderate, and severe PH, respectively, P < .0001). Long-term survival was related to preoperative sPAP (5-year survival: 88%, 79%, 65%, and 53% for none, mild, moderate, and severe PH, respectively; P < .0001). In multivariable analyses, sPAP was a predictor of both operative mortality (odds ratio, 1.023 per 1 mm Hg increase; 95% confidence interval, 1.003–1.044; P = .0270) and late death (hazard ratio, 1.018 per 1 mm Hg increase; 95% confidence interval, 1.007–1.028; P = .001). Among 284 patients with isolated degenerative mitral regurgitation due to leaflet prolapse, actuarial survival was 97.5%, 91.2%, and 80.5% for none, mild, and moderate to severe PH, respectively ( P = .0002). Conclusions Preoperative sPAP is a powerful predictor of early and late survival after mitral valve operation for mitral regurgitation. Even modest increases in sPAP adversely affect outcomes. Mitral valve operation should be performed before the development of PH.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Up to 30% of patients presenting with ascending aortic disease are deemed inoperable. Ascending aortic endovascular repair provides an alternative option for these patients.
From 2018 to 2019, 13 ...patients who were considered to have prohibitive risk for open ascending aortic repair underwent endovascular repair. Aortic disease included type A dissection (n = 8), pseudoaneurysm (n = 3), penetrating ulcer (n = 3), and chronic aortic aneurysm (n = 1). Ascending aortic stent placement with thoracic endovascular aortic repair was performed in 9 patients, endovascular cuff extension was inserted in 3, and in 1 patient endovascular coil embolization was undertaken. Preoperative and follow-up electrocardiogram-gated computed tomographic analysis was performed to compare the remodeling effect of the stent on the aorta. The median follow-up time was 13 months.
The stent graft was successfully implanted in all patients (100%). Operative mortality and stroke rate were 15% (2 of 13) and 8% (1 of 13), respectively. One patient required transcatheter aortic valve replacement for severe aortic insufficiency 5 months after ascending thoracic endovascular aortic repair. The location of the aortic pathologic process was in zone 0A in 2 patients, zone 0B in 7 patients, and zone 0C in 3 patients. No endoleak was observed after the ascending endovascular repair in 9 patients (70%). Follow-up computed tomographic scan analysis revealed a tendency of favorable aortic remodeling in the mid-ascending and descending aorta.
Ascending aortic stent placement for ascending aortic disease is feasible and is associated with favorable aortic remodeling. Despite persistent perfusion to the false lumen in a subset of patients, there is minimal aortic dilation at short-term follow-up with excellent survival.
Background:
The aim of this study was to evaluate the ipsilateral lower extremity (ILE) outcomes of patients who underwent bedside angiography via the distal perfusion catheter while on femoral ...veno-arterial extracorporeal membrane oxygenation (VA ECMO).
Methods:
This is a retrospective analysis of all patients placed on VA ECMO at a single center from January 2017 to December 2019 who underwent bedside angiography via the distal perfusion catheter.
Results:
Twenty-four patients underwent bedside angiography via the distal perfusion catheter after being placed on VA ECMO. A vasodilator was directly administered in three patients for suspected spasm. One patient had distal thrombus and underwent thrombectomy and fasciotomy. One patient had a dislodged catheter and underwent thrombectomy, fasciotomy, and replacement of the catheter. One patient had severe ILE ischemia, however was not intervened upon due to critical acuity. Finally, one patient had inadvertent placement in the saphenous vein and had a new catheter placed in the SFA. No patients underwent amputation. Ultimately, 21 patients (87.5%) had no ILE compromise at the end their ECMO course. Survival to decannulation was 66.7% (n = 16).
Conclusions:
Bedside angiography of the distal perfusion catheter is feasible and can be a useful adjunct in informing the need for further intervention to the ILE.
Classifications:
extracorporeal membrane oxygenation, ischemia
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Introduction
It remains unclear whether patients who will not accept allogeneic blood transfusion can be managed successfully with veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO). The ...objective of our study was to determine what percentage of V-A ECMO patients were managed without allogeneic blood transfusion.
Methods
This was a retrospective, observational cohort study of patients with cardiogenic shock requiring V-A ECMO between January 2016 and January 2019. The primary outcome was avoidance of any allogeneic blood transfusion.
Results
Of the 206 patients included, 23 (11.2%) were managed without any allogeneic blood transfusion. Fourteen (60.9%) avoided allogeneic blood transfusion during their entire hospitalization. “No-transfusion” patients were younger, more commonly men, were less likely to have a prior diagnosis of hypertension or coronary artery disease, had higher baseline hemoglobin, had higher SAVE scores, and were less likely to have received aspirin before ECMO. No patients in the “no-transfusion” group had major bleeding compared to 35% of patients in the blood transfusion group (p < 0.001). In-hospital mortality was 17.4% for those who avoided blood transfusion and 41.5% for those who received blood transfusion (p = 0.04). ECMO duration was significantly shorter in patients who avoided blood transfusion compared to those who received blood transfusion (median 3.5 vs 7 days, p < 0.001).
Conclusions
Select patients can be successfully managed on V-A ECMO without allogeneic blood transfusion. Jehovah’s Witnesses and other patients with objections to allogeneic transfusion might be offered V-A ECMO if its anticipated duration is short (e.g. <7 days) and baseline hemoglobin concentration is high (e.g. ≥10 mg/dL).
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Background In contrast to mitral valve repair, residual and recurrent regurgitation after tricuspid valve (TV) repair for functional tricuspid regurgitation (TR) is common. We have systematically ...used undersized, rigid 3-dimensional annuloplasty rings to treat functional TR. Methods From March 2006 to October 2009, 101 consecutive patients with moderate or greater functional TR underwent TV repair with an undersized rigid 3-dimensional annuloplasty ring. All patients had a predischarge echocardiography evaluation in a core echocardiography laboratory. Follow-up echocardiography was available for 96% of surviving patients. Mean follow-up was 17 ± 9 months. Results Twenty-nine percent of patients had undergone previous cardiac operations, 74% were in New York Heart Association functional class III or IV, and 48% had atrial fibrillation. Mitral valve operations were performed in 93 patients, aortic valve operations in 17, coronary artery bypass grafting in 21, and CryoMaze procedures in 40. Size 26 or 28 rigid tricuspid annuloplasty rings were used in 88% of patients, and no ring larger than a 28 has been used since November 2008. The operative mortality rate was 6% (n = 6). Freedom from significant TR (TR > moderate) at hospital discharge, as assessed by the clinical core laboratory, was 97%. Only 3% of patients had TR greater than moderate during follow-up. No patient required TV reoperation. New postoperative permanent pacemakers were inserted in 3 patients. Conclusions Tricuspid valve repair with an undersized (size 26 or 28) rigid 3-dimensional annuloplasty ring is the method of choice for reliable and durable treatment of functional TR.
Background Tricuspid valve infective endocarditis (TVIE) is uncommon. Patients are traditionally treated with antibiotics alone, and indications for operation are not clearly established. We report ...our operative single-center experience. Methods We retrospectively reviewed 56 patients who underwent operations for TVIE between January 2002 and December 2012. Results Methicillin-resistant Staphylococcus aureus was present in 41% of patients, septic pulmonary emboli in 63%, moderate/severe tricuspid regurgitation in 66%, and 86% were intravenous drug abusers. Patients underwent early operation if there was concomitant left-sided endocarditis with indications for operation (n = 18), atrial septal defect (n = 6), infected pacemaker lead (n = 4), or prosthetic TVIE (n = 1). The remaining 27 patients were treated with intravenous antibiotics. Five patients completed a 6-week course of intravenous antibiotics before requiring an operation for symptomatic severe tricuspid regurgitation or persistent bacteremia. Twenty-two patients did not complete the antibiotic therapy and underwent operation for symptomatic severe tricuspid regurgitation (n = 15), persistent fevers/bacteremia (n = 3), or patient-specific factors (n = 4). Valve repair was successful in 57% of patients. Overall operative mortality was 7.1%. No operative deaths occurred in patients with isolated native TVIE. Recurrent TVIE was diagnosed in 21% (5 of 24) of the replacement group and in 0% (0 of 32) in the repair group. Use of repair was strongly protective against recurrent TVIE ( p < 0.01). Conclusions In contrast to previously published reports of high operative mortality with TVIE, this experience demonstrates improved outcomes with low morbidity and mortality, particularly for native isolated TVIE. Future prospective comparisons between surgically and medically treated patients may help to further define indications and timing for operation for patients with TVIE.
Background:
Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest has improved mortality in post-cardiac surgery patients; however, loss of neurologic function remains one ...of the main and devastating complications. We reviewed our experience with ECPR and investigated the effect of cannulation strategy on neurologic outcome in adult patients who experienced cardiac arrest following cardiac surgery that was managed with ECPR.
Methods:
Patients were categorized by central versus percutaneous peripheral VA-extracorporeal membrane oxygenation (ECMO) cannulation strategy. We reviewed patient records and evaluated in-hospital mortality, cause of death, and neurologic status 72 hours after cannulation.
Results:
From January 2010 to September 2019, 44 patients underwent post-cardiac surgery ECPR for cardiac arrest. Twenty-six patients received central cannulation; 18 patients received peripheral cannulation. Mean post-operative day of the cardiac arrest was 3 and 9 days (p = 0.006), and mean time between initiation of CPR and ECMO was 40 ± 24 and 28 ± 22 minutes for central and peripheral cannulation, respectively. After 72 hours of VA-ECMO support, 30% of centrally cannulated patients versus 72% of peripherally cannulated patients attained cerebral performance status 1–2 (p = 0.01). Anoxic brain injury was the cause of death in 26.9% of centrally cannulated and 11.1% of peripherally cannulated patients. Survival to discharge was 31% and 39% for central and peripheral cannulation, respectively.
Conclusions:
Peripheral VA-ECMO allows for continuous CPR and systemic perfusion while obtaining vascular access. Compared to central cannulation, a peripheral cannulation strategy is associated with improved neurologic outcomes and decreased likelihood of anoxic brain death.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Caseous calcification of the mitral annulus is a rare variant of mitral annular calcification where liquefaction and caseation result in formation of a mass at the border of the calcified annulus. ...Limited reports of operative therapy for caseous calcification of the mitral annulus describe wide excision and gross débridement of the mass, a technique that can cause perioperative stroke. We present a strategy of limited incision and drainage of the liquid material, closure of the incision, and subsequent suture obliteration of the cavity and mitral valve repair or replacement. In our experience, this technique is safe and has not been associated with perioperative stroke.
Background The incidence of reoperative mitral valve (MV) surgical procedures is increasing, representing more than 10% of all MV operations in the United States. Previous clinical series have ...reported mortality rates of 5% to 18% and reentry injury rates of 5% to 10% for reoperative MV operations. Methods Between January 2004 and June 2012, 1,312 MV operations were performed on 1,275 patients. We excluded 234 patients who underwent small incision primary right thoracotomy, 11 redo operations with first or second operation other than sternotomy, and 10 emergent operations, leaving 1,056 MV operations for analysis (first-time sternotomy, 926 88%; repeat sternotomy, 130 (12%). Preoperative computed tomography was performed for all repeat sternotomy patients. Patients at risk for reentry injury were identified, and protective strategies were applied systemically before resternotomy procedures. Results Among 130 patients undergoing reoperative MV operations, 35% (46/130) had prior coronary artery bypass grafting (CABG), 15% (19/130) aortic valve operations, and 61% (80/130) MV operations. Sixteen percent (21/130) had more than one previous sternotomy. Operative mortality was 4.6% (43/926) for first-time procedures and 4.6% (6/130) for reoperative MV operations. Intraoperative injury (innominate vein) occurred during repeat sternotomy in 2 (1.5%) patients. Stroke occurred in 3 patients (2%) who underwent repeat sternotomy and in 22 (2%) who underwent first-time sternotomy. On multivariable analysis, preoperative New York Heart Association function class, concomitant CABG, dialysis, and higher pulmonary artery pressures were associated with operative mortality, and repeat sternotomy was not. Conclusions With careful planning and execution, outcomes for reoperative MV operations in contemporary practice are favorable and are identical with those for first-time operations.
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