Sutureless self-expandable aortic bioprostheses rely on radial forces for stabilization, raising concern that these devices may increase the risk of postoperative conduction disease. The purpose of ...this study was to determine the incidence of conduction disorders after sutureless aortic valve replacement (AVR) with the Perceval S (Sorin Group, Saluggia, Italy) bioprosthesis.
Between June 2011 and March 2013, 108 consecutive patients underwent sutureless AVR with the Perceval S prosthesis. Six patients (6%) had a permanent pacemaker (PPM) preoperatively and were excluded from the present study. Mean electrocardiographic follow-up was 14.6 ± 6.0 months.
Mean age was 79.2 ± 4.8 years (52% female). During the postoperative period, 34 patients (34%) had first-degree atrioventricular block, 2 (2%) had Mobitz-II atrioventricular block, and 16 (16%) had complete atrioventricular block. New-onset left bundle branch block and right bundle branch block were observed in 33 patients (33%) and 22 patients (22%), respectively. Inhospital postoperative PPM implantation was required in 23 patients (23%). Preoperative aortic valve area, age more than 85 years, and preoperative right bundle branch block were found to be independently associated with inhospital PPM implantation or new-onset postoperative conduction disorder. At follow-up, 3 more patients (3%) underwent PPM implantation. The cumulative incidences of PPM dependency and ventricular pacing more than 25% of the time were 18% ± 11% and 21% ± 10%, respectively, at 18 months.
In the present study, the postoperative PPM implantation rate (23%) after sutureless AVR with the Perceval S prosthesis was high. Surgical strategies aimed at mitigating this risk should be further investigated.
Delirium is an acute syndrome that involves fluctuating changes in attention and cognition. Although delirium is the most common neurologic complication after cardiac operation, data about its impact ...on long-term outcomes are lacking. The purpose of this systematic review was to examine the effect of postoperative delirium (PoD) on long-term outcomes, including morbidity, probability of death, cognitive decline, institutionalization, and health-related quality of life (HRQoL) in patients undergoing cardiac operation. After performing this systematic review we determined that PoD after cardiac operation is associated with an increased risk of probability of death and readmission to the hospital and a decrease in cognitive function, overall function, and HRQoL.
Abstract Objectives The aim of this study was to determine immediate results and long-term outcomes after surgical management of paravalvular leak (PVL). Methods Between 1995 and 2012, a total of 190 ...patients underwent primary surgical repair (n = 142) or valve replacement (n = 48) for a PVL at our institution. The PVL was mild in 6 (3%) patients, moderate in 85 (45%), moderate to severe in 84 (44%), and severe in 15 (8%). Among these, 120 (63%) had PVL in the mitral position, 63 (33%) had PVL in the aortic position, and 7 (4%) had PVL in both valves. Mean follow-up was 5.3 ± 4.6 years. Results Mean age at surgery was 63 ± 12 years (64% men). Operative mortality occurred in 13 (7%) patients (10 8% in mitral; 2 3% in aortic; and 1 14% in double valve procedures). Survival at 1, 5, and 10 years was 85% ± 3%, 73% ± 4%, and 56% ± 5%, respectively. The cumulative incidence of PVL recurrence was 3% ± 1%, 14% ± 3%, and 32% ± 6%, at 1, 5, and 10 years, respectively. The number of previous surgeries was a predictor of survival and PVL recurrence. Freedom from New York Heart Association class ≥III was 96% ± 2%, 82% ± 4%, and 58% ± 6%, at 1, 5, and 10 years, respectively. The freedom from rehospitalization for heart failure was 92% ± 2%, 83% ± 4%, and 67% ± 6%, at 1, 5, and 10 years. Conclusions Surgical treatment of PVL resulted in acceptable outcomes. Nevertheless, the continued risk of PVL recurrence is higher in patients who have had multiple previous surgeries. More studies are needed to compare these results with the transcatheter PVL reduction technique.
Abstract Objective Bicuspid aortic valve (BAV) is generally considered to be a contraindication to sutureless aortic valve replacement (AVR). The aim of this study was to evaluate the feasibility and ...perioperative outcomes of this technique in patients with BAV. Methods From June 2011 to January 2014, a total of 25 patients who underwent sutureless AVR had documented BAV. Thirteen patients (52%) had median sternotomy, and 12 patients (48%) a minimally invasive approach. Results The study population included 17 (68%) men with a median age of 77.8 ± 5.4 years. The mean EuroSCORE II was 3.4% ± 2.6%. Concomitant procedures included coronary artery bypass grafting in 8 patients (32%), 2 AVRs (8%), 1 mitral valve repair (4%), 1 septal myomectomy (4%), and 1 atrial septal defect closure (4%). The mean transaortic valve gradient decreased from 49.4 ± 15.7, to 14.5 ± 5.4 mm Hg postoperatively. The mean aortic valve area increased from 0.78 ± 0.18, to 1.75 ± 0.43 cm2 postoperatively. Five patients (20%) suffered from atrioventricular block that required permanent pacemaker implantation. Two patients (8%) suffered a stroke. No major paravalvular leakage occurred, and no postoperative valve migration. In-hospital mortality occurred in 1 patient (4%). The mean intensive care unit length of stay was 3 ± 2 days postoperatively. Conclusions This study demonstrates that a sutureless aortic valve can be deployed in patients with BAV without increasing the risk of paravalvular leakage. BAV should not be considered a contraindication to sutureless AVR.
Abstract Objective Postoperative atrial fibrillation (POAF) is one of the most frequent complications encountered after heart surgery and significantly increases complications and mortality. An ...obstructed chest tube, leaving unevacuated blood around the heart and lungs, can lead to atrial inflammation, which can trigger POAF. The aim of this study was to assess the effectiveness of chest drainage incorporating active tube clearance (ATC) system in reducing the rate of POAF. Methods This retrospective analysis based on 300 consecutive patients undergoing heart surgery compared 142 patients allocated to an ATC drainage protocol to 158 controls managed with standard chest drainage. Using a 1:1 propensity score match, 214 patients were included in paired analysis (107 in each group). The primary endpoint was POAF. Results Unmatched patients managed with ATC chest drainage protocol had a reduction of 34% in their POAF rate compared to those managed with standard drains (23% vs 35%, P=0.01). In the matched cohort, ATC was associated with a reduction of 31% in the rate of POAF (24% vs 35%, P =0.09) and a trend toward shorter postoperative length of stay (5.0 4.0; 7.0 vs 6.0 5.0; 8.0, P =0.08). In multivariate analysis, chest drainage with ATC showed a protective effect on POAF with odds ratio of 0.5 (95% confidence interval, 0.1-0.9; P =0.02). Conclusions The use of an ATC chest drainage protocol may be associated with reduced POAF. Our results suggest that efforts to maintain chest tubes patency might be useful to reduce the incidence of POAF.
Objective Cardiogenic shock is associated with poor clinical outcomes. Extracorporeal life support is used in most centers for short-term circulatory support. Alternatively, the Impella LP 5.0 and ...right direct (RD) microaxial ventricular assist device (Abiomed, Danvers, Mass) can provide isolated left and right ventricular support, respectively. Methods A retrospective, single center review was performed on all patients receiving circulatory assistance with either extracorporeal life support or Impella ventricular assist device. All Impella LP 5.0 were inserted via the femoral artery, while the RD system required sternotomy. Results Twenty-nine patients received ventricular assist device support (Impella LP 5.0; n = 24; and Impella RD; n = 5), whereas 32 patients were placed on extracorporeal life support. The baseline characteristics of patients with cardiogenic shock, assisted by Impella or extracorporeal life support, were similar, but the etiology of cardiogenic shock was distributed differently in the 2 groups ( P = .008). Forty-one percent of the Impella patients and 47% of the extracorporeal life support patients were weaned from support. The 30-day mortality (44% in the extracorporeal life support vs 38% in the Impella group) and proportion of patients discharged home (41% in the extracorporeal life support vs 59% in the Impella group) were not statistically different between the 2 groups. Arterial thrombosis was less frequent in the Impella group (3.4% vs 18.8%; P = .04). Blood product transfusions were less frequent in the Impella group ( P < .001). Conclusions Both extracorporeal life support and axial flow pumps provided adequate support in patients with various etiologies of cardiogenic shock. Axial-flow pump may be an optimal type of support for patients with univentricular failure, whereas extracorporeal life support could be reserved for patients with biventricular failure or combined respiratory and circulatory failure.
The risk of aortic valve replacement (AVR) for patients after mediastinal radiation therapy (MRT) remains unaccounted for in traditional risk scores. The aim of this study was to examine ...perioperative and midterm outcomes in patients undergoing AVR after MRT in the current era.
From 2000 to 2016, 49 consecutive patients previously exposed to MRT underwent AVR with or without concomitant procedures at a single center. Patients were divided into two groups: isolated AVR (n = 18) and AVR with concomitant procedures (n = 31). The logistic European System for Cardiac Operative Risk Evaluation II mean score was 2.8% ± 3.4% and The Society of Thoracic Surgeons mean score was 1.7% ± 1.5%. Median follow-up was 6.6 years and was 90% complete within 12 months of study closure.
Overall inhospital mortality was 10% (0% in the isolated group versus 16% in the concomitant group; p = 0.14). A total of 21 patients (47%) died at follow-up. Mean interval to death was 2.0 ± 1.1 years from surgery in the isolated group versus 1.4 ± 1.6 years in the concomitant group (p = 0.18). Actuarial survival was 93% ± 6%, 73% ± 11%, and 65% ± 13%, at 1, 3, and 5 years, respectively, in the isolated group versus 74% ± 8%, 44% ± 11%, and 37% ± 11% in the concomitant group (p = 0.03).
Isolated AVR can be performed safely in patients with MRT-induced disease. In contrast, AVR with concomitant procedures is associated with high mortality, which is vastly underestimated using traditional risk scores. In both groups, survival at 5 years is markedly impaired.
Abstract Objective Several risk-scoring systems have been developed to predict surgical mortality and complications in cardiac surgical patients, but none of the current systems include factors ...related to the intraoperative period. The purpose of this study was to develop a score that incorporates both preoperative and intraoperative factors so that it could be used for patients admitted to a cardiac surgical intensive care unit (ICU) immediately after surgery. Method Preoperative and intraoperative data from 30,350 patients in four hospitals were used to build a multiple logistic regression model estimating 30-day mortality after cardiac surgery. Sixty percent of the patients were used as a derivation group and forty percent as a validation group. Results Mortality occurred in 2.6% of patients (n = 790). Preoperative factors identified in the model were age, female sex, emergency status, pulmonary hypertension, peripheral vascular disease, renal dysfunction, diabetes, peptic ulcer disease, history of alcohol abuse, and refusal of blood products. Intraoperative risk factors included the need for an intra-aortic balloon pump, ventricular assist device or extracorporeal membrane oxygenation leaving the operating room, presence of any intraoperative complication reported by the surgeon, the use of inotropes, high-dose vasopressors, red blood cell transfusion, and cardiopulmonary bypass time. When used after surgery at ICU admission, the model had C-statistics of 0.86 in both derivation and validation sets to estimate the 30-day mortality. Conclusions Preoperative and intraoperative variables can be used on admission to a cardiac surgical ICU to estimate 30-day mortality. The score could be used for risk stratification after cardiac surgery and evaluation of performance of cardiac surgical ICUs.
Abstract With more than 60 years of continuous development and improvement, a variety of temporary Mechanical Circulatory Support (MCS) devices and implantation strategies exist, each with unique ...advantages and disadvantages. A thorough understanding of each available device is essential for optimizing patient outcomes in a fiscally responsible manner. This state-of-the-art review examines the entire range of commonly available peripheral and centrally-cannulated temporary MCS devices, including intra-aortic balloon pumps, the Impella family of microaxial pumps, the TandemHeart pump and percutaneous cannulas, centrally-cannulated centrifugal pumps such as CentriMag and Rotaflow, and extra-corporeal membrane oxygenation. Several factors need detailed consideration when contemplating MCS in any given patient, mandating a balanced, algorithmic approach for these sick patients. Here we describe our approach to MCS, emphasizing the need for multidisciplinary input to consider patient-related, logistical, and institutional factors. Evidence is summarized and referenced where available, but given the lack of high-quality evidence, current best practice is described. Future directions for investigation are discussed, which will better define patient and device selection, and optimize MCS-specific patient care protocols.
Implantation of left ventricular assist devices through small incisions, avoiding cardiopulmonary bypass, may decrease the activation of the inflammatory and coagulation cascades and decrease ...bleeding and vasoplegia. One patient with severe, inotrope-dependant cardiomyopathy received the HeartWare left ventricular assist device (HeartWare Inc, Framingham, MA) through an upper ministernotomy and left minithoracotomy. The outflow graft was connected to the ascending aorta, and the inflow of the left ventricular assist device was attached through to the apex of the heart. The apical puncture was performed under rapid ventricular pacing, followed by insertion of the inflow of the pump. The patient was extubated rapidly and discharged home 14 days later.
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