New permanent pacemaker (PPM) implantation after concomitant atrial fibrillation (AF) ablation has been associated with surgical ablation (SA). We sought to determine factors for PPM use, and early ...rhythm recovery.
From 2004 through 2019, 6135 patients underwent valve surgery and were grouped by: No AF (n=4584), AF no SA (n=346), and AF with SA (n=1205) to evaluate predischarge PPM and 3-month rhythm recovery (intrinsic heart rate >40bpm).
Overall, 282 (4.6%) patients required a predischarge PPM: atrioventricular node dysfunction (AVND) in 75.3%, sick sinus syndrome (SSS) in 19.1%, both (5%) and indeterminate (0.7%). Patients with AF had more PPMs: AF with SA (7.9%) versus AF no SA (6.9%) versus No AF (3.6%; P<0.001). For AF patients, PPM rates were not significantly higher for ablation patients (7.6% SA vs 6.9% AF no SA; P=0.56). There were differences in PPM by SA lesion set (biatrial 12.8%; left atrial only 6.1%; pulmonary vein isolation 3.0%; P<0.001). Among AF treated patients with 3-month PPM follow-up, rhythm recovery was common 35/62 (56.5%) and did not differ by lesion set. Rhythm recovery was 63/141 (44.7%) in the AVND group versus 24/35 (68.6%) in the SSS group (P=0.011). In propensity score-matched groups, late survival was similar (P=0.63) for new PPM patients.
Avoiding conduction system trauma and delaying implantation reduces the need for postoperative PPM. Rhythm recovery within 3 months is frequent, especially for patients with SSS. A conservative approach to the implantation of a new PPMs is warranted.
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Guideline recommendations for mechanical or bioprosthetic (BP) valve for MVR by age remains controversial. We sought to determine bovine pericardial valve durability by age, and risk of ...reintervention.
This retrospective study between 2 large university-based cardiac surgery programs examined patients who underwent BP MVR from 2004 to 2020. Follow-up was obtained through June 2022. Durability outcomes involving structural valve deterioration (SVD) were compared by age decile.
Of 1544 available patients, mean age was 66±13 years and 652 (42%) were < 65 years old. Indications for MVR were: MR>2+ 53% n=813; mitral stenosis 44% n=650; endocarditis 18% n=277 and reoperation in 39% n=602. Concomitant procedures were AVR 28% n=426; Tricuspid valve 36% n=550; CAB 19% n=290. Thirty-day mortality was 5.4%. In follow-up (clinical: median IQR 75 25-129 months) reoperation for endocarditis, and new stroke were low (0.30 and 1.06 per 100 patient/years, respectively). The cumulative incidence of MV reintervention for SVD among all patients was 6.2% at 10 years 9.0% at 12 years with no statistical difference in SVD among patients between the ages of 40 and 70 years (p=0.1). Among 90 patients with MV reintervention, 30-day mortality after reintervention was 4.7% (n=2) for 43 MViV and 6.4% (n=3) among 47 reoperation patients.
Bovine pericardial MVR is a durable option for younger patients. The opportunity to avoid anticoagulation and the associated risks with mechanical MVR may be of benefit to patients. These insights may provide data needed to revise the current guidelines.
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Guidelines do not address preoperative atrial fibrillation when considering adding tricuspid annuloplasty to mitral surgery. Our purpose was to determine the occurrence of late tricuspid ...regurgitation in patients with less than moderate tricuspid regurgitation undergoing surgery for degenerative mitral regurgitation and the importance of atrial fibrillation and tricuspid annular dilation.
From 2004 to 2017, 1021 patients underwent surgery for degenerative mitral regurgitation; 869 (85%) had less than moderate tricuspid regurgitation, and 846 (97%) underwent repair. Preoperative atrial fibrillation was present in 199 patients and ablated in 194 patients (97%). Tricuspid annular diameter was measured in 657 of 869 patients (76%).
For patients who did not receive tricuspid annuloplasty, recurrent moderate or more late tricuspid regurgitation was 8% (45/576) in the no atrial fibrillation group and 25% (38/154) in the atrial fibrillation group (P < .001; odds ratio, 2.42). In 75.2% of patients (494/657), the tricuspid annulus was less than 4.0 cm; in 17% of patients (112), the tricuspid annulus was 4.0 to 4.4 mm (mean 41.1 mm); and in 7.8% of patients (51), the tricuspid annulus was 45 mm or more (47.8 mm). Only tricuspid diameter 45 mm or more was a risk for late tricuspid regurgitation (P = .002; odds ratio, 3.25). Progression to moderate or higher tricuspid regurgitation was associated with an increase in long-term mortality: unadjusted hazard ratio, 3.58 (2.04-6.29) (P < .001); adjusted hazard ratio, 2.37 (1.23-4.57) (P = .010).
Preoperative atrial fibrillation is an important risk factor for late tricuspid regurgitation despite concomitant ablation surgery. Tricuspid annular dilation was not associated with late tricuspid regurgitation until the annulus was 45 mm or greater. Progression to moderate or greater tricuspid regurgitation was associated with an increase in late mortality.
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Retained blood syndrome (RBS) encompasses complications, acute and chronic, related to inflammation created by retained intrathoracic blood after cardiac surgery. Reports suggest that active chest ...tube clearance devices reduce RBS and may lower the rates of reoperation for bleeding and postoperative atrial fibrillation.
In a prospective study (April 2015–October 2017), 1367 patients meeting the study inclusion criteria (1113 control subjects with conventional chest tubes and 254 patients with active chest tube clearance devices the ATC group) underwent cardiac surgery through primary sternotomy.
Groups were similar in their preoperative and intraoperative characteristics. No differences were found in overall RBS occurrence (4.3% in the ATC group vs 5.3% in the control group; P = .527), including the components of reexploration for bleeding (2.0% 5/254 for the ATC group and 2.4% 27/1113 for the control group; P = .664) and pleural effusion requiring intervention (3.1% 8/254 vs 3.6% 40/1113; P = .729). Postoperative atrial fibrillation (20.8% 52/254 vs 20.2 % 221/1113; P = .837) and 30-day mortality were also similar (3.5% vs 2.2%; P = .231). Postoperative blood product use was 31.9% (81/254) in the ATC group and 28.7% (319/1113) in the control group (P = .308). Some complications were more common in the ATC group, including septicemia (2.4% 6/254 vs 0.7% 8/1113; P = .019) and renal failure (3.9% 10/254 vs 1.7% 19/1113; P = .026). Median postoperative length of stay was shorter in the ATC group (5 days vs 6 days; P = .025).
Active chest tube clearance devices were not associated with improved postoperative outcomes related to RBS at the study institution (Northwestern Medicine, Chicago, IL). Given the additional cost, the nursing effort to maintain the active chest tube clearance devices, and the lack of apparent benefit, this study did not demonstrate the value of using such devices in cardiac surgery.
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To determine the prevalence of concomitant aortic regurgitation (AR) in cardiac surgery and the outcomes of treatment options.
Between April 2004 and June 2018, 3289 patients underwent coronary ...artery bypass, mitral valve, or aortic aneurysm surgery without aortic stenosis. AR was graded none/trivial (score = 0), mild (score = 1+), or moderate (score = 2+). Patients with untreated 2+ AR were compared with those with 0 or 1+ AR, and to those with 2+ AR who had aortic valve surgery. Thirty-day and late survival, echocardiography, and clinical outcomes were compared using propensity score matching.
One hundred thirty-eight patients (4.2%) had 2+ AR; and 45 (33%) received aortic valve repair (n = 9) or replacement (n = 36) in the treated group and were compared with 2765 untreated patients with 0 AR and 386 patients with 1+ AR. Valve surgery was more common with anatomic leaflet abnormalities: bicuspid aortic valve (9% vs 0%; P < .01), rheumatic valve disease (16% vs 3%; P < .01), and calcification (47% vs 27%; P = .021). In unadjusted analysis, lower preoperative AR grade was associated with increased 10-year survival (P < .001). At year 10, progression to more-than-moderate AR among moderate AR patients was 2.6% and late intervention rate was 3.1%. In the untreated 2+ AR group, on last follow-up echocardiogram, 58% had improvement in AR, 41% remained 2+, and only 1% progressed to severe AR.
Aortic valve surgery in select patients with concomitant moderate AR can be added with minimal added risk, but untreated AR does not influence long-term survival after cardiac surgery and rarely required late intervention.
Freedom from more-than-moderate AR at 10 years in concomitant moderate AR. Display omitted
Sutureless/rapid-deployment (SRD) valves for aortic valve replacement (AVR) are new surgical bioprosthetic valves that allow for expedited implantation and facilitate minimally invasive approaches. ...Although clinical trial data are available for SRDs in the United States, how their clinical outcomes compare with traditional stented bioprosthetic (SBP) valves is unknown in a post-approval, commercial setting.
The Society of Thoracic Surgery Adult Cardiac Surgery Database was queried for patients who underwent an AVR. Transcatheter AVR cases were excluded. Thirty-day outcomes were compared between SRD valves (Perceval S LivaNova, Houston, TX and Intuity Elite Edwards Lifesciences, Irvine CA) and SBP valve patients. The SRD and SBP patients were propensity score–matched in a 1:(up to) 3 ratio. Primary outcome was 30-day mortality and secondary outcomes were major comorbidities, paravalvular regurgitation, and predischarge pacemaker implant.
Propensity score matching resulted in 4486 SRD patients and 13,215 SBP patients. The SRD recipients had more permanent pacemakers (11.4% vs 4.9%, P < .001) shorter cross-clamp times (median: 68 vs 86 minutes, P < .001), and fewer full sternotomies (75% vs 77% , P < .024) than SBP but similar 30-day mortality (3.1% vs 3.1%, P = .98) and moderate or greater paravalvular regurgitation (0.2% vs 0.1%, P = .21).
SRD implantation was associated with reduced operative times and smaller incisions. Rates of 30-day mortality, major comorbidities, and perivalvular regurgitation were similar between SRD and SBP patients. Longer follow-up is needed to determine the implications of increased permanent pacemaker implantation rates in SRD patients.
During degenerative mitral repair, surgeons must decide if further repair is warranted for residual mild mitral regurgitation. We examined the incidence of mild mitral regurgitation, late ...echocardiographic and clinical outcomes, and influence of surgical experience in decision making.
From April 2004 to June 2018, 1155 of 1195 patients with pure degenerative disease underwent repair (97% repair rate). Propensity score matching was performed between patients with trace/no mitral regurgitation and patients with mild residual mitral regurgitation. Late echocardiographic outcome and freedom from reoperation were compared using competing-risks models. A comparison of outcomes of the referent surgeon (89.8% of repairs) with all other surgeons was performed.
Mild mitral regurgitation was present in 73 patients (6%). Propensity score–matched analyses compared 69 patients with mild mitral regurgitation with 198 patients without mitral regurgitation. Late moderate or greater mitral regurgitation was higher in those with mild mitral regurgitation than in those with no mitral regurgitation (17% vs 7%, P = .033), as was late moderate-severe or greater mitral regurgitation (6% vs 1%, P = .016). Ten-year freedom from reoperation was low in both groups (99.5% no vs 96.9% mild; P = .10). The referent surgeon had fewer patients with mild residual mitral regurgitation (6% vs 11%, P = .027) and less progression of mitral regurgitation compared with other surgeons (late moderate or greater mitral regurgitation 6% vs 15%, P = .002).
Residual mild mitral regurgitation was uncommon, and late progression to moderate or greater mitral regurgitation was rare and never led to late mitral reoperation. Experienced surgeons may be better able to determine repairs likely to remain stable, and most mild residual mitral regurgitation does not require re-repair.
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