The Journal of Thoracic and Cardiovascular Surgery - Articles in Press

Impact of early fundoplication or gastrostomy tube on midterm outcomes for patients with single ventricle - Corrected Proof

2012-01-30

Objective: Patients with single-ventricle heart disease experience early and late failure during and after staged palliation. Little is known about the factors related to continued risk of transplantation and mortality after completion of staged palliation. The long-term outcome of patients with single-ventricle disease who require a gastric fundoplication early in life has not been assessed.Methods: A total of 155 patients with single-ventricle disease who survived their first-stage palliative procedure were enrolled in a research registry. Demographic and anatomic variables were collected, and the families were contacted every 6 months for prospective documentation of transplant-free survival. Medical records were reviewed for the details of noncardiac surgical procedures. Univariate and multivariate regression analyses were performed to determine the impact of early gastric surgery on late transplant-free survival.Results: There were 93 male patients, median gestational age was 38 weeks, and birth weight was 3.2 kg. Sixty-five patients (42%) had hypoplastic left heart syndrome. Twelve patients (7.7%) had a genetic syndrome. Thirty-two patients (21%) had a fundoplication or a gastrostomy tube at less than 2 years of age. Median follow-up was 4.3 years (range, 79 days to 10 years). Race, gender, gestational age, birth weight, and genetic syndrome did not alter midterm transplant-free survival. Need for fundoplication or gastrostomy was an independent risk factor for decreased transplant-free survival (P = .003; hazard ratio, 4.29), which was unchanged when adjusted for all covariates.Conclusions: The need for early fundoplication or gastrostomy is associated with decreased transplant-free survival for patients with palliated single-ventricle heart disease.

A novel approach to the aneurysmal coronary artery fistula - Corrected Proof

Christopher H. May, Douglas R. Johnston, Wael A. Jaber, Gosta B. Pettersson — 2012-01-30

Coronary artery fistulas are a rare subset of coronary artery anomalies, with a prevalence of approximately 0.2%. They involve an abnormal connection between a coronary artery and a cardiac chamber or large thoracic vessel such as the coronary sinus or pulmonary artery. The majority are small fistulas, which are well tolerated and typically found incidentally. A large fistula causes symptoms of high cardiac output failure, such as dyspnea, fatigue, angina, and volume overload. The coronary artery feeding the fistula can dilate and become aneurysmal. In cases of large symptomatic fistulas, surgical repair is imperative to stop progression of symptoms and return the patient to his or her prior functional status. When the coronary artery is substantially dilated, simple ligation of the fistula may not be the best option because of increased risk of thrombosis or rupture. The following report describes a novel surgical solution to this problem.

Right lung ischemia induces contralateral pulmonary vasculopathy in an animal model - Corrected Proof

2012-01-30

Objective: The study objective was to determine whether the vasculopathy seen in nonobstructed lung regions in chronic thromboembolic pulmonary hypertension is induced by the local blood flow increase or by factors released by the ischemic lung.Methods: Three groups of 10 piglets were studied 5 weeks after right pulmonary artery ligation, right pneumonectomy, or right pulmonary artery dissection (sham). Pulmonary vascular resistance, pulmonary arterial vasoreactivity, and morphometry were measured, and gene expressions of factors involved in vascular smooth muscle cell proliferation were quantified.Results: Left lung blood flow was similarly increased after right pneumonectomy and right pulmonary artery ligation. Compared with right pneumonectomy, right pulmonary artery ligation resulted in left lung vasculopathy with increased pulmonary vascular resistance (P = .0009), medial hypertrophy of the distal pulmonary artery (P < .0001), and decreases in maximal relaxation to acetylcholine (P = .013) and endothelial nitric oxide synthase gene expression (P = .041). These values were similar after sham and right pneumonectomy. In the left lung, right pulmonary artery ligation increased the gene expressions for insulin-like growth factor (P = .034), platelet-derived growth factor (P = .0006), and vascular endothelial growth factor (P = .0105) compared with right pneumonectomy and sham. Whereas endothelin-1 gene expression was not affected, expressions of endothelin-1 receptors A and B were downregulated after right pneumonectomy (P = .048 and P = .039, respectively) and right pulmonary artery ligation (P = .033 and P = .028, respectively).Conclusions: Pulmonary vasculopathy was absent in the remaining lung 5 weeks after right pneumonectomy but developed in the nonobstructed lung regions 5 weeks after right pulmonary artery ligation, suggesting that factors released by the ischemic lung induced vascular remodeling in the contralateral lung. This endocrine process may involve the release of factors involved in vascular smooth muscle cell proliferation.

Implementation of a comprehensive blood conservation program can reduce blood use in a community cardiac surgery program - Corrected Proof

2012-01-30

Objective: The study objective was to determine the effects of implementing a blood conservation algorithm on blood product use and outcomes in a community cardiac surgery program.Methods: A blood management strategy including lower hemoglobin transfusion threshold and algorithm-driven decisions was adopted. Intraoperatively, point-of-care testing was used to avoid inappropriate component transfusion. A low prime perfusion circuit was adopted. Blood was withdrawn from patients before initiating bypass when possible. Patients undergoing coronary and valve procedures were included. Outlier patients receiving more than 10 units packed red blood cells were excluded. Data were collected for 6 months as a baseline group (group I). A 3-month period of program implementation was allotted. Data were subsequently collected for 6 months and comprised the study patients (group II). Prospective data were collected on demographics, blood use, and outcomes.Results: Group I comprised 481 patients, and group II comprised 551 patients. Group II received fewer units of packed red blood cells, fresh-frozen plasma, and cryoprecipitate than group I. There was no difference in platelets transfused. Total blood product use was reduced by 40% in group II (P < .001). The overall 30-day mortality was 1.3%. There were no differences in mortality, reoperation for bleeding, or other postoperative outcomes between the groups.Conclusions: Implementation of a comprehensive blood conservation algorithm can be rapidly introduced, leading to reductions in blood and component use with no detrimental effect on early outcomes. Point-of-care testing can direct component transfusion in coagulopathic cases, with most coagulopathic patients requiring platelets. Further research will determine the effects of reduced transfusions on long-term outcomes.

Intraoperative use of recombinant activated factor VII during complex aortic surgery - Corrected Proof

2012-01-30

Objective: Postoperative bleeding is a major cause of morbidity and mortality after complex aortic surgery. Intraoperative coagulopathy is a well-known culprit in this process. Recombinant activated factor VII is increasingly used for the postoperative management of such bleeding. We report our experience with the intraoperative use of this agent.Methods: We performed a propensity-matched analysis on 376 retrospectively identified patients who underwent aortic root, arch, or ascending aortic replacement surgeries from 1999 to 2010. We matched a total of 58 patients: recombinant activated factor VII–treated group (n = 29) and nonrecombinant activated factor VII–treated group (n = 29). We compared the matched patients on re-exploration, mortality, bleeding-related events, use of blood and blood products, length of intensive care unit stay, duration of hospitalization, and thrombotic complications.Results: Propensity-matched patients had similar preoperative and intraoperative characteristics. The mean dose of recombinant activated factor VII group was 23 ± 12 μg/kg. We found significantly lower rates of surgical re-exploration (P = .004), fewer prolonged intubations (P = .004), less total chest tube output (P = .01), and fewer units of packed red blood cells (P = .01) and fresh-frozen plasma (P = .04) transfused postoperatively in the recombinant activated factor VII group. There was no significant difference in mortality (P = 1), duration of intensive care unit stay (P = .44) or hospital stay (P = .32), or thrombotic complications between the groups (P = .5).Conclusions: We recommend the intraoperative administration of low-dose recombinant activated factor VII but limited to the management of persistent, nonsurgical, mediastinal bleeding in aortic surgery. Further prospective randomized studies and larger cohorts are needed to verify these findings.

Atypical malignant late infective endocarditis of Melody valve - Corrected Proof

Mehul Patel, Laurence Iserin, Damien Bonnet, Younes Boudjemline — 2012-01-30

The Melody transcatheter pulmonary valve (Medtronic, Inc, Minneapolis, Minn) is approved for interventional treatment of dysfunctional right ventricular outflow tract (RVOT) conduits as an alternative to surgical replacement. We report a series of 4 patients with infective endocarditis of a Melody valve. The data are derived from the REVALV trial, evaluating outcomes after Melody valve implantation in France.

Mitral valve annuloplasty and papillary muscle relocation oriented by 3-dimensional transesophageal echocardiography for severe functional mitral regurgitation - Corrected Proof

2012-01-30

Objective: The study of the mitral valve apparatus and its modifications during functional mitral regurgitation (FMR) is better revealed by 3-dimensional (3D) transesophageal echocardiography (TOE). To plan mitral valve repair by annuloplasty and papillary muscle (PPM) relocation, we proposed a valve repair procedure oriented by the new main features obtained by real-time 3D TOE reconstruction of the mitral valve apparatus.Methods: Since January 2008, 25 patients with severe FMR before mitral valve repair were examined. Mean coaptation depth and mean tenting area were 1.3 ± 0.2 cm and 3.2 ± 0.5 cm2, respectively. Intraoperative 2D and 3D TOE were performed, followed by a 3D offline reconstruction of the mitral valve apparatus. A schematic mitral valve apparatus model was obtained. A geometric model like a truncated cone was traced in according to the preoperative measurements. The size of the prosthetic ring was selected preoperatively according to the anterior leaflet surface. The expected truncated cone after annuloplasty was retraced. A conventional normal coaptation depth about 0.6 cm was used to detect the new position of the PPM tips.Results: Offline reconstruction of the mitral valve apparatus and respective truncated cone were feasible in all patients. The expected position of the PPM tips desirable to reach a normal tenting area with a coaptation depth 0.6 cm or less was obtained in all patients. After surgery, all parameters were calculated and no statistically significant difference was found compared with the expected data.Conclusions: PPM relocation plus ring annuloplasty reduce mitral valve tenting and may improve mitral valve repair results for patients with severe FMR. This technique may be easily and precisely guided by preoperative offline 3D echocardiographic mitral valve reconstruction.

Evolution of operative techniques and perfusion strategies for minimally invasive mitral valve repair - Corrected Proof

2012-01-30

Objective: Perfusion strategies and operative techniques for minimally invasive mitral valve repair have evolved over time. During the past decade, our institution’s approach has progressed from a port access platform with femoral perfusion to predominantly a central aortic cannulation through a right anterior minithoracotomy incision. We analyzed this institutional experience to evaluate the impact of approach on patient outcomes.Methods: Between 1995 and 2007, 1282 patients (mean age, 59.3 years; range, 18-99 years) underwent first-time, isolated mitral valve repair using a minimally invasive technique. Patient demographics included peripheral vascular disease (3.2%), chronic obstructive pulmonary disease (8.3%), atherosclerotic aorta (6.5%), cerebrovascular disease (4.3%), and ejection fraction less than 30% (4.3%). Retrograde perfusion was performed in 394 (30.7%) of all patients and endoaortic balloon occlusion in 373 (29.1%); the operative technique was a right anterior minithoracotomy in 1264 (98.6%) and left posterior minithoracotomy in 18 (1.4%). The etiology of mitral disease was degenerative in 73.2%, functional in 20.6%, and rheumatic in 2.4%. Data were collected prospectively using the New York State Cardiac Surgery Report System and a customized minimally invasive surgery data form. Logistic analysis was used to evaluate risk factors and outcomes; operative experience was divided into tertiles.Results: Overall hospital mortality was 2.0% (25/1282). Mortality was 1.1% (10/939) for patients with degenerative etiology and 0.4% (3/693) for patients younger than 70 years of age with degenerative valve disease. Risk factors for death were advanced age (P = .007), functional etiology (P = .010; odds ratio [OR] = 3.3), chronic obstructive pulmonary disease (P = .013; OR = 3.4), peripheral vascular disease (P = .014; OR = 4.2), and atherosclerotic aorta (P = .03; OR = 2.8). Logistic risk factors for neurologic events were advanced age (P = .02), retrograde perfusion (P = .001; OR = 3.8), and emergency procedure (P = .01; OR = 66.6). Interaction modeling revealed that the only significant risk factor for neurologic event was the use of retrograde perfusion in high-risk patients with aortic disease (P = .04; OR = 8.5). Analysis of successive tertiles during this 12-year experience revealed a significant decrease in the use of retrograde arterial perfusion (89.6%, 10.4%, and 0.0%; P < .001) and endoaortic balloon occlusion (89.3%, 10.7%, and 0%; P < .001). The overall frequency of postoperative neurologic events was 2.3% (30/1282) and decreased from 4.7% in the first tertile to 1.2% in the second and third tertiles (P < .001).Conclusions: Central aortic cannulation through a right anterior minithoracotomy for mitral valve repair allows excellent outcomes in patients with a broad spectrum of comorbidities and has become our preferred approach for most patients undergoing mitral valve repair. Retrograde arterial perfusion is associated with an increased risk of stroke in patients with severe peripheral vascular disease and should be reserved for select patients without significant atherosclerosis.

Discussion - Corrected Proof

2012-01-30

Dr James Maxwell (Missoula, Mont). Allogeneic blood transfusion has been under intense review for the last decade, and a 2006 review in Circulation referred to post-cardiac surgery transfusions as a silent epidemic. Significant evidence of the harmful effects of transfusion have accumulated to the point where the current search is for meaningful evidence to support transfusion absent life-threatening hemorrhage. Still, the frequency of transfusion after cardiac surgery in the United States varies widely from 0% to 75%. It is in this context that the authors implemented a comprehensive blood conservation program in a community hospital. The study is actually a retrospective comparison of historical controls versus transfusion rates after coronary artery bypass grafting, valve, and combined cases. The statistical analysis suggested a reduction in transfusion of FFP, red blood cells, and cryoprecipitate. Despite stopping aspirin for 10 days preoperatively, a reduction in platelet transfusion was not noted. For reasons unclear, excluded from analysis from both groups were outliers requiring more than 10 units of blood, although the statistical impact of this was nil. A 41% reduction in blood transfusion was achieved over the study period and persisted for the 3 months after the study interval. The post-study transfusion rate was approximately 50% for the combined group. There were no differences in major morbidity between the groups. Despite improvements in transfusion rates, no reductions in prespecified morbidity were noted. I also note the overall excellent results of your group across the board for surgical outcomes, which may explain why there was no improvement in surgical outcomes despite improvements in blood use.

Rationale and initial experience with the Tri-Ad Adams tricuspid annuloplasty ring - Corrected Proof

2012-01-27

Controversy exists regarding the indication and method of repair of functional tricuspid regurgitation (TR) in patients undergoing mitral valve surgery. Whereas the American College of Cardiology/American Heart Association guidelines recommend tricuspid repair in the setting of severe TR, tricuspid repair is advised for less than severe TR in the setting of annular dilation or pulmonary hypertension. Although multiple repair strategies exist, the use of a ring annuloplasty (semirigid remodeling rings vs flexible bands) is the preferred method of therapy to avoid short- and long-term recurrence of TR. The new Tri-Ad Adams annuloplasty ring combines elements of semirigid and flexible bands that will not only allow for annular remodeling in the region of the right ventricular free wall but also potentially reduce injury to the conduction system with its flexible and “open” ends. In this article, we discuss the rational for an aggressive approach to functional tricuspid regurgitation, and show our initial clinical experience with the Tri-Ad Adams annuloplasty ring.

Vodka to prevent postoperative adhesions: Another unsuspected cardiac benefit of alcohol - Corrected Proof

Philippe Menasché — 2012-01-27

The prevention of postoperative adhesions to make sternal re-entry safer and to avoid its potentially associated life-threatening complications has been a longstanding endeavor in cardiac surgery. The multiplicity of the proposed strategies, which range from the topical application of agents stimulating the pericardial fibrinolytic function by mesothelial cells to the placement of resorbable or nonresorbable pericardial substitutes, clearly demonstrates that none of these strategies has proven convincing enough to gain wide clinical acceptance. On the basis of the study of Lassaletta, Chu, and Sellke, it would seem that this list of compounds and devices can now be completed by…vodka.

Myocardial tissue elastic properties determined by atomic force microscopy after stromal cell–derived factor 1α angiogenic therapy for acute myocardial infarction in a murine model - Corrected Proof

2012-01-24

Objectives: Ventricular remodeling after myocardial infarction begins with massive extracellular matrix deposition and resultant fibrosis. This loss of functional tissue and stiffening of myocardial elastic and contractile elements starts the vicious cycle of mechanical inefficiency, adverse remodeling, and eventual heart failure. We hypothesized that stromal cell–derived factor 1α (SDF-1α) therapy to microrevascularize ischemic myocardium would rescue salvageable peri-infarct tissue and subsequently improve myocardial elasticity.Methods: Immediately after left anterior descending coronary artery ligation, mice were randomly assigned to receive peri-infarct injection of either saline solution or SDF-1α. After 6 weeks, animals were killed and samples were taken from the peri-infarct border zone and the infarct scar, as well as from the left ventricle of noninfarcted control mice. Determination of tissues' elastic moduli was carried out by mechanical testing in an atomic force microscope.Results: SDF-1α–treated peri-infarct tissue most closely approximated the elasticity of normal ventricle and was significantly more elastic than saline-treated peri-infarct myocardium (109 ± 22.9 kPa vs 295 ± 42.3 kPa; P < .0001). Myocardial scar, the strength of which depends on matrix deposition from vasculature at the peri-infarct edge, was stiffer in SDF-1α–treated animals than in controls (804 ± 102.2 kPa vs 144 ± 27.5 kPa; P < .0001).Conclusions: Direct quantification of myocardial elastic properties demonstrates the ability of SDF-1α to re-engineer evolving myocardial infarct and peri-infarct tissues. By increasing elasticity of the ischemic and dysfunctional peri-infarct border zone and bolstering the weak, aneurysm-prone scar, SDF-1α therapy may confer a mechanical advantage to resist adverse remodeling after infarction.

Dysregulated gene expression of extracellular matrix and adhesion molecules in saphenous vein conduits of hemodialysis patients - Corrected Proof

Yongxin Sun, Wenjun Ding, Qiang Wei, Zhenya Shen, Chunsheng Wang — 2012-01-24

Objective: The incidence of cardiovascular disease was approximately 10 times higher in hemodialysis patients with end-stage renal disease than in the general population. The saphenous vein is the most commonly used conduit for coronary artery bypass grafting. However, the extracellular matrix and adhesion molecule characteristics of saphenous vein in hemodialysis patients remain unclear. The aim of the present study was to survey the extracellular matrix gene expression profile of the saphenous vein in hemodialysis patients undergoing coronary artery bypass grafting.Methods: A total of 34 patients undergoing elective coronary artery bypass grafting were enrolled. Of the 34 patients, 15 with end-stage renal disease required maintenance hemodialysis. The control group consisted of the other 19 patients without preoperative renal disease. Samples of the saphenous vein were obtained at coronary artery bypass grafting. The expression profile of the extracellular matrix genes was analyzed by microarray. The tissue matrix metallopeptidase/tissue inhibitor of metallopeptidase protein activities in the saphenous vein were evaluated by immunocytochemistry and Western blotting.Results: Nineteen extracellular matrix and adhesion molecule-focused genes demonstrated at least a threefold difference in expression between the 2 groups. Upregulation was observed in 16 genes, and 3 genes appeared to be downregulated. Notable imbalanced matrix metallopeptidase/tissue inhibitor of metallopeptidase protein activities of saphenous vein exposed to end-stage renal disease conditions was found.Conclusions: The results from present study suggest that the native extracellular matrix gene expression profile of the saphenous vein conduits in hemodialysis patients show signs of the vein graft disease process before coronary surgery. Furthermore, some preoperative profiles of hemodialysis patients undergoing coronary artery bypass grafting might provide some useful clues regarding vein graft quality and prompt adjustment in surgical strategy.

Prosthetic aortic valve–pexy: Stitch closure of the aortic valve in a patient with a ventricular assist device - Corrected Proof

Salil V. Deo, Soon J. Park, Lawrence J. Sinak, Alfredo L. Clavell — 2012-01-24

Intermittent opening of the mechanical aortic valve after placement of a ventricular assist device (VAD) can lead to an increased risk of thromboembolism. It has been recommended to close the aorta with a patch or replace it with a bioprosthesis. Both these methods, however, increase the ischemic time. A single-stitch method to close the mechanical aortic valve has been described; however, placement of the suture as illustrated in the article is technically very difficult. We therefore describe our modification as used in a patient with a mechanical aortic valve undergoing VAD placement and include intraoperative photographs and an illustration.

Gene polymorphisms and cytokine plasma levels as predictive factors of complications after cardiopulmonary bypass - Corrected Proof

2012-01-20

Objective: Cardiopulmonary bypass remains associated with significant morbidity and mortality, in part caused by a systemic inflammatory response that is unpredictable and variable among patients. Several limited studies have suggested associations of cytokine plasma levels or gene polymorphisms with outcome after cardiopulmonary bypass. The present study was to determine the relationships between several circulating cytokines and their polymorphisms (single nucleotide polymorphisms), and the occurrence of postoperative clinical events in patients who underwent coronary artery bypass grafting under cardiopulmonary bypass.Methods: Patients were genotyped for single nucleotide polymorphisms of LTA (Cys13Arg, +252A>G), TNF (-308G>A), IL6 (-597G>A, -572G>C, -174G>C), IL10 (-592C>A, c.∗117C>T), and APOE (Cys112Arg, Arg158Cys). Serum samples were collected preoperatively, immediately after cardiopulmonary bypass, and at different postoperative time points to measure cytokine serum levels by enzyme-linked immunosorbent assay. The clinical end point was the composite of postoperative death, low cardiac output syndrome, myocardial infarction, sepsis, and acute renal insufficiency.Results: Single nucleotide polymorphisms IL6-572GC+CC/IL10-592CC were associated with the clinical end point (P = .032 and P = .009, respectively). In addition to preoperative clinical conditions, the other factor associated with the clinical end point was interleukin-10 plasma levels 24 hours after surgery (P = .017). On the basis of these results, a predictive model of postoperative complications after coronary artery bypass grafting was created.Conclusions: Our data suggest that focused genetic testing of the IL6-572G>C and IL10-592C>A single nucleotide polymorphisms might be a tool for identifying patients at the highest risk of poor tolerance to the inflammatory response to cardiopulmonary bypass and for implementing strategies to mitigate it, provided the generalization of these tests makes them reasonably affordable and thus favorably shifts their cost-to-benefit ratio.

In vitro assessment of prosthesis type and pressure recovery characteristics: Doppler echocardiography overestimation of bileaflet mechanical and bioprosthetic aortic valve gradients - Corrected Proof

2012-01-20

Objective: Pressure recovery results in Doppler gradients greater than catheter gradients and is well established in association with bileaflet mechanical aortic valves. Because pressure recovery is influenced by orifice geometry, it might manifest differently with various valve prostheses. If true, then the reliability of Doppler echocardiography for the estimation of aortic valve gradients might be different with different prostheses. The purpose of the present study was to test, in an in vitro setting, the degree to which pressure recovery results in Doppler overestimation of gradients for three commonly used aortic valve prostheses.Methods: Carpentier Edwards Perimount, Medtronic Mosaic, and St. Jude Medical bileaflet prostheses were tested under various flow conditions in a pulsatile mock flow loop with a normal aorta size. Mean pressure gradient was assessed with transducers 1 cm and 10 cm distal to the valve and with Doppler echocardiography. Pressure recovery was defined as the difference between the Doppler gradient and a 10-cm gradient. The percentage of the maximum pressure gradient composed of pressure recovery and the percentage of pressure recovery complete 1 cm distal to the valve were calculated.Results: There was substantial pressure recovery for all valves in all flow states. Pressure recovery was responsible for 50% or more of the Doppler gradients for almost all conditions and was more than 70% complete within 1 cm for almost all conditions. Multivariate analysis found that flow and valve area (but not valve type) were predictors of pressure recovery; that flow was the major predictor of the percentage of Doppler gradient composed of pressure recovery (with minor contributions from the aorta size and prosthesis type); and that valve type and aorta size were the major predictors of the percentage of pressure recovery complete at 1 cm.Conclusions: In an in vitro model with a normal aorta size, substantial pressure recovery occurred with all three aortic valve prostheses. Although statistically significant differences were found between valve types in the percentage of pressure recovery and percentage of pressure recovery complete at 1 cm, the differences were small and clinically unimportant. Clinically, among patients with an ascending aorta diameter less than 3.0 cm, Doppler echocardiography likely substantially overestimates aortic valve mean gradient, regardless of prosthesis type.

Comparative analysis of antifibrinolytic medications in pediatric heart surgery - Corrected Proof

2012-01-20

Objectives: Recent studies suggest adverse events associated with aprotinin in adults may not occur in children, and there is interest in further pediatric study of aprotinin. However, there are limited contemporary data comparing aprotinin with other available antifibrinolytics (aminocaproic acid [ACA] and tranexamic acid [TXA]) to guide current practice and aid in potential trial design. We performed a comparative analysis in a large multicenter cohort.Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database (2004-2008) was linked to medication data from the Pediatric Health Information Systems Database. Efficacy and safety outcomes were evaluated in multivariable analysis adjusting for patient and center factors overall and in neonates and those undergoing redo sternotomy.Results: A total of 22,258 patients (25 centers) were included: median age, 7.6 months (interquartile range, 2.6-43.4 months). Aprotinin (vs no drug) was associated with a significant reduction in combined hospital mortality/bleeding requiring surgical intervention overall (odds ratio [OR], 0.81; 95% confidence intervals [CI], 0.68-0.91) and in the redo sternotomy subgroup (OR, 0.57; 95% CI, 0.40-0.80). There was no benefit in neonates and no difference in renal failure requiring dialysis in any group. In comparative analysis, there was no difference in outcome in aprotinin versus ACA recipients. TXA (vs aprotinin) was associated with significantly reduced mortality/bleeding requiring surgical intervention overall (OR, 0.47; 95% CI, 0.30-0.74) and in neonates (OR, 0.30; 95% CI, 0.15-0.58).Conclusions: These observational data suggest aprotinin is associated with reduced bleeding and mortality in children undergoing heart surgery with no increase in dialysis. Comparative analyses suggest similar efficacy of ACA and improved outcomes associated with TXA.

Experience with more than 100 total artificial heart implants - Corrected Proof

2012-01-16

Objective: The SynCardia Total Artificial Heart (SynCardia Systems Inc, Tucson, Ariz) has been used as a bridge to cardiac transplantation in 930 patients worldwide and in 101 patients in our program. Our experience with SynCardia Total Artificial Heart implantation documents its indications, safety, and efficacy.Methods: Data regarding preoperative condition, mortality, and morbidity have been reviewed and analyzed.Results: From January 1993 to December 2009, 101 patients had bridge to transplant procedures with the SynCardia Total Artificial Heart. Ninety-one percent of cases were Interagency Registry for Mechanically Assisted Circulatory Support profile 1, and the remaining 9% of cases were failing medical therapy on multiple inotropic medications. The mean support time was 87 days (median, 53 days; range, 1–441 days). Pump outputs during support were 7 to 9 L/min. Adverse events included strokes in 7.9% of cases and take-back for hemorrhage in 24.7% of cases. Survival to transplantation was 68.3%. Causes of death of 32 patients on device support included multiple organ failure (13), pulmonary failure (6), and neurologic injury (4). Survival after transplantation at 1, 5, and 10 years was 76.8%, 60.5%, and 41.2%, respectively. The longest-term survivor is currently alive 16.4 years postimplantation.Conclusions: These patients were not candidates for left ventricular assist device therapy and were expected to die. The SynCardia Total Artificial Heart offers a real alternative for survival with a reasonable complication rate in appropriate candidates who otherwise might have been assigned to hospice care.

Discussion - Corrected Proof

2012-01-16

Dr Hari Mallidi (Stanford, Calif). When you boil the study down to its essence, it is basically a case series of poor quality from an epidemiologic standpoint in terms of guiding further future therapy, but it is a case series of approximately 100 patients treated with INTERMACS class 1 status treated with TAH over a period of 15 to 20 years. The devil is really in the details, and unfortunately the details were not really provided in the talk or the article.

Do we increase the operative risk by adding the Cox Maze III procedure to aortic valve replacement and coronary artery bypass surgery? - Corrected Proof

Niv Ad, Linda Henry, Sharon Hunt, Sari D. Holmes — 2012-01-16

Objective: Recent reports from Europe and the United States have suggested that patients presenting for open surgery with a significant history of atrial fibrillation (AF) have inferior early and late outcomes if AF is left untreated. On the other hand, there is reluctance among surgeons to treat AF surgically, especially when atriotomies may be required otherwise, which is the case with aortic valve replacement (AVR) or coronary artery bypass grafting (CABG). The objective of this study was to explore the potential impact of the addition of the Cox Maze III procedure on short- and long-term outcomes of patients when combined with AVR or CABG.Methods: Since 2005, 485 patients have undergone the Cox Maze III procedure at Inova Heart and Vascular Institute, 95 of whom had a full Cox Maze III with an AVR or CABG (Cox Maze III/AVR = 30; Cox Maze III/CABG = 47; Cox Maze III/AVR/CABG = 18). In addition, 4255 patients with no history of AF underwent AVR or CABG without surgical ablation (AVR = 422; CABG = 3518; AVR/CABG = 315). Data from our CABG, valve, and AF registries were used for analyses. Patients with and without the Cox Maze III were propensity score matched using a 0.10 caliper to improve balance on clinical and demographic variables. Differences in perioperative and postoperative outcomes by group were evaluated using the Fisher exact test, and a Kaplan–Meier survival analysis was completed. Health-related quality of life (Short Form 12) was obtained at baseline and 6 months post-surgery (n = 72).Results: All 95 patients who underwent the Cox Maze III were propensity score matched with patients who did not undergo the Cox Maze III. Mean age (t = 0.3, P = .79) and European System for Cardiac Operative Risk Evaluation score (t = −1.8, P = .07) were similar between the groups. There were no significant differences in major postoperative morbidities between the groups despite the Cox Maze III group being on bypass longer (164.4 vs 108.8 minutes; t = −9.8, P < .001). Pacemaker implantation was significantly higher in the Cox Maze III group (P = .03). Survival during follow-up (mean = 35 months) was not different between patients who did and did not undergo the Cox Maze III procedure (log rank = 0.49, P = .48). Improvement in physical health-related quality of life was similar for both groups (F = 0.01, P = .94). At 1 year, 94% of the patients (60/64) who underwent the Cox Maze III procedure were in sinus rhythm (81% off class I and III antiarrhythmic drugs).Conclusions: The addition of the Cox Maze III procedure to AVR or CABG did not convey an increase in major morbidity and perioperative risk. Patients who underwent the Cox Maze III procedure demonstrated similar survival over time with improvement in health-related quality of life. The Cox Maze III should not be denied to patients in whom the cardiac surgical procedure does not include atriotomies because of the perceived increased operative risk. The Cox Maze III may significantly improve their outcome.

The relationship between plasma concentrations of ionized calcium and magnesium with cardiac energetics and systemic oxygen transport in neonates after the Norwood procedure - Corrected Proof

Santokh Dhillon, Xiaoyang Yu, Gencheng Zhang, Sally Cai, Jia Li — 2012-01-16

Objective: We sought to determine the relationship between plasma calcium and magnesium concentrations with postoperative systemic hemodynamics and oxygen transport in neonates after the Norwood procedure.Methods: Postoperative systemic oxygen consumption was continuously measured using respiratory mass spectrometry for 72 hours in 17 neonates. Arterial, superior vena caval and pulmonary venous blood gases and pressures, plasma calcium, and lactate levels were measured at 2- to 4-hour intervals to calculate cardiac output, rate pressure product, cardiac power output, systemic oxygen delivery, and oxygen extraction ratio. Plasma magnesium levels were measured at 2- to 8-hour intervals.Results: Plasma calcium levels decreased in the first 8 hours from 1.08 ± 0.13 mmol/L to 0.98 ± 0.08 mmol/L, followed by an increase to 1.10 ± 0.26 mmol/L at 72 hours (P < .0001). Mg2 þ change was significantly related to time after logarithmic transformation, rapidly decreasing from 1.62 ± 0.25 mg/L to 0.90 ± 0.15 mg/L in the first 40 hours and further decreasing slowly thereafter to 0.64 ± 0.13 mg/L at 72 hours (P < .0001). Plasma magnesium levels had a significant positive correlation with cardiac output (P = .008) and cardiac power output (P = .01), and a negative correlation with heart rate (P = .05). Plasma magnesium levels correlated positively with systemic oxygen delivery and negatively with systemic oxygen consumption (P = .08 for both), resulting in significant negative correlations with oxygen extraction ratio (P = .04) and lactate levels (P = .05). For a given cardiac power output, plasma magnesium showed a significantly negative correlation with rate pressure product (P = .01). Plasma calcium levels showed the opposite trend, which was statistically insignificant except for lactate (P = .007).Conclusions: Plasma magnesium may exert favorable effects on myocardial energetics and systemic oxygen transport in neonates after the Norwood procedure, whereas plasma calcium may be harmful. Maintaining a relatively high level of plasma magnesium and a low level of plasma calcium may improve myocardial work efficiency and the balance of systemic and myocardial oxygen transport.

Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: A propensity-matched study with 30-year follow-up - Corrected Proof

2012-01-16

Objective: Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied.Methods: Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm.Results: There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001).Conclusions: Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered.

HeartWare continuous-flow ventricular assist device thrombosis: The Bad Oeynhausen experience - Corrected Proof

Nadia Aissaoui, Jochen Börgermann, Jan Gummert, Michiel Morshuis — 2012-01-16

The HeartWare (HeartWare International, Inc, Framingham, Mass), ventricular assist device (VAD) is a small, third-generation, implantable continuous-flow VAD. Despite this system’s advantages, the rates of thrombus formation and thromboembolic events are not negligible and can reach 8%.

Angiotensin-converting enzyme insertion/deletion polymorphism is a risk factor for thoracic aortic aneurysm in patients with bicuspid or tricuspid aortic valves - Corrected Proof

2012-01-16

Objective: The angiotensin-converting enzyme (ACE) is highly expressed in the aneurysmal vascular wall, in both animal models and human disease. Genetic variations in ACE could be crucial in determining the risk of thoracic aortic aneurysm (TAA). The aim of the present study was to examine the role of ACE insertion/deletion polymorphism on the risk of TAA in patients with bicuspid aortic valves or tricuspid aortic valves.Methods: We enrolled 216 patients (158 men; age, 58.9 ± 14.9 years) with TAA, associated with bicuspid aortic valves (n = 105) and tricuspid aortic valves (n = 111) compared with 312 patients (252 men; age, 54.6 ± 11.0 years) with angiographically proven coronary artery disease and 300 healthy controls (91 men; age, 40.4 ± 10.5 years).Results: The genotype distribution of ACE insertion/deletion was significantly different between the patients with TAA compared with both the control group (P = .0005) and the coronary artery disease group (P = .03). The genotypes were not different between the control group and the coronary artery disease group (P = .3). Compared with the controls, both the bicuspid aortic valve patients (P = .0008) and tricuspid aortic valve patients (P < .0001) had a greater frequency of allele D. The aortic diameters were significantly different among the three genotypes (48.3 ± 6.6, 45.3 ± 8.9, 39.9 ± 8.7 for the DD, DI, and II genotypes, respectively; P = .0002). A synergistic effect between the ACE D allele and hypertension was found for both an increased aortic diameter (P = .003) and the risk of TAA (P < .001). On multivariate logistic regression analysis, D allele (odds ratio, 3.0; 95% confidence interval, 1.1–8.1; P = .03) was a significant predictor of TAA.Conclusions: ACE insertion/deletion polymorphism represents a genetic biomarker for TAA. These findings could have a significant effect on both the early detection and effective pharmacologic treatment of aortic disease.

Discussion - Corrected Proof

2012-01-16

Dr John Doty (Murray, Utah). This study represents a propensity-based analysis of adding surgical ablation to AVR and coronary bypass. These are procedures that typically do not require an atriotomy like a mitral valve operation. This shows that adding a concomitant modified Cox Maze operation will have similar outcomes but does not increase mortality and supports the safety and efficacy of AF ablation operations.

Discussion - Corrected Proof

2012-01-16

Dr Anthony Furnary (Portland, Ore). Dr Galbut, you and your coauthors have presented a nonrandomized series of BITA and SITA groups and divided them into terciles of EF. Propensity matching was done using 14 preoperative variables, and both raw and unmatched were presented. There was a 14-year follow-up in group I, less than 30%, and no differences in operative or survival were seen. There were survival differences in the group with 30% to 50% EF and the group with greater than 50% EF. In the reduced group with 30% to 50% EF, there was a 22-year follow-up and a raw mortality difference of 17% at 10 years, which amounted to approximately a 5-year difference in median survival in the unmatched population. Now when the groups were propensity matched, those numbers decreased from 17% at 10 years to 4% at 10 years and the median survival decreased from 5 years to approximately 2 years. The number of patients who are left at the end of the whole thing at 20 years was less than 5% of the patient population, and there are only 37 matched patients at 20 years. I do not think we can make any statistically valid conclusions on those data. In the normal EF group and the greater than 50% EF group, there was a 28-year follow-up with a raw mortality difference of approximately 16% at 10 years and 12% at 20 years, which amounted to a 4.4% difference in median survival. Now once again when the groups were propensity matched using those 14 characteristics, the differences were markedly reduced again from 17% to 7% at 10 years and from 12% to 2% at 20 years, and the median survival was now down to 7 months when the propensity matching was carried out. So statistically speaking, as we all know with nonrandomized and retrospective studies, when there are significant differences in the raw outcomes that become smaller and smaller with the more matching and risk adjustment we do, we really have to look closely at the risk adjustment techniques and the statistical techniques to find out if there is anything we missed that might account for the remaining differences. Because retrospective studies, as you know, cannot prove causality, we have to take a critical look at that. There are at least 2 variables that may not have been accounted for in this incredible study that may have had an impact on long-term survival. The 2 things that I looked at in your data (and I appreciate the article in advance) are year of operation and operating surgeon or operating center. Year of operation is important because the salutary effects of newer adjunctive treatments that came to the fore over the 22 years of this study between 1972 and 1994 on long-term survival are significant, such as myocardial protection techniques, the advent of statins, and the use of beta-blockers, angiotensin-converting enzyme inhibitors, and implantable cardioverter defibrillators to prolong survival (especially for those with lower EF). The year of operation might be an important piece to put in there to mitigate some of those factors. I have 5 questions for you.

Evaluation of the use of an induced puripotent stem cell sheet for the construction of tissue-engineered vascular grafts - Corrected Proof

2012-01-13

Objective: The development of a living, tissue-engineered vascular graft (TEVG) holds great promise for advancing the field of cardiovascular surgery. However, the ultimate source and time needed to procure these cells remain problematic. Induced puripotent stem (iPS) cells have recently been developed and have the potential for creating a pluripotent cell line from a patient’s own somatic cells. In the present study, we evaluated the use of a sheet created from iPS cell–derived vascular cells as a potential source for the construction of TEVG.Methods: Male mouse iPS cells were differentiated into embryoid bodies using the hanging-drop method. Cell differentiation was confirmed by a decrease in the proportion of SSEA-1–positive cells over time using fluorescence-activated cell sorting. The expression of endothelial cell and smooth muscle cell markers was detected using real-time polymerase chain reaction (PCR). The differentiated iPS cell sheet was made using temperature-responsive dishes and then seeded onto a biodegradable scaffold composed of polyglycolic acid–poly-l-lactide and poly(l-lactide-co-ε-caprolactone) with a diameter of 0.8 mm. These scaffolds were implanted as interposition grafts in the inferior vena cava of female severe combined immunodeficiency/beige mice (n = 15). Graft function was serially monitored using ultrasonography. The grafts were analyzed at 1, 4, and 10 weeks with histologic examination and immunohistochemistry. The behavior of seeded differentiated iPS cells was tracked using Y-chromosome fluorescent in situ hybridization and SRY real-time PCR.Results: All mice survived without thrombosis, aneurysm formation, graft rupture, or calcification. PCR evaluation of iPS cell sheets in vitro demonstrated increased expression of endothelial cell markers. Histologic evaluation of the grafts demonstrated endothelialization with von Willebrand factor and an inner layer with smooth muscle actin- and calponin-positive cells at 10 weeks. The number of seeded differentiated iPS cells was found to decrease over time using real-time PCR (42.2% at 1 week, 10.4% at 4 weeks, 9.8% at 10 weeks). A fraction of the iPS cells were found to be Y-chromosome fluorescent positive at 1 week. No iPS cells were found to co-localize with von Willebrand factor or smooth muscle actin-positive cells at 10 weeks.Conclusions: Differentiated iPS cells offer an alternative cell source for constructing TEVG. Seeded iPS cells exerted a paracrine effect to induce neotissue formation in the acute phase and were reduced in number by apoptosis at later time points. Sheet seeding of our TEVG represents a viable mode of iPS cell delivery over time.

Discussion - Corrected Proof

2012-01-13

Dr John E. Mayer, Jr. (Boston, Mass). Congratulations on a very interesting study and on successfully overcoming the technical challenges of both the cell seeding problem and the implant of these tiny vascular grafts. Thank you for sending the manuscript and figures in advance.

Impairment of pericardial leaflet structure from balloon-expanded valved stents - Corrected Proof

2012-01-13

Objective: Malpositioning is one of the major problems in transcatheter aortic valve implantation. To evaluate the influence of mechanical balloon inflation on aortic valve stent positioning, the expansion process and the impact on the valve leaflet’s structure were investigated.Methods: Custom-made stents were laser cut from a 22-mm diameter stainless steel tube and mounted with a glutaraldehyde-treated bovine pericardial valve. The valved stents were crimped onto a standard balloon catheter and expanded by inflation of the balloon with 2 bar for 3 seconds. Expansion was studied using a high-speed camera, and the histology of the pericardial tissue was analyzed.Results: The valved stents were fully expanded within 3 seconds. Balloon inflation was observed to be asymmetric starting proximally. At the beginning of expansion, the valved stents were pulled proximally. During further inflation, the stents slipped distally on the balloon and experienced a total displacement of 13.5 mm. Macroscopic examination showed severe imprinting of the stent struts into the pericardial tissue. Histology revealed disrupted tissue layers and collagen fibers.Conclusions: Analysis of valved stent expansion showed a displacement of the stent on the catheter during balloon inflation. Therefore, precise placement of the valved stent cannot be accomplished. Histologic analysis of the expanded pericardial tissue revealed disruption of collagen fibers. Disruption of pericardial tissue structures due to balloon expansion may result in early functional valve failure.

Surgical treatment of residual systolic anterior motion after otherwise successful percutaneous transluminal septal myocardial ablation: A case report - Corrected Proof

2012-01-13

Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by asymmetrically distributed left ventricular hypertrophy, often accompanied by left ventricular outflow tract obstruction (LVOTO). LVOTO in patients with HOCM commonly exists in addition to mitral valve abnormalities, such as increased mitral leaflet area, length, and laxity, along with anterior displacement of the papillary muscles. These abnormalities predispose toward systolic anterior motion (SAM), which is a protrusion of the anterior mitral valve leaflet into the left ventricular outflow tract, adding to the severity of LVOTO and a variable degree of mitral regurgitation.

Prognostic value of myocardial fibrosis in patients with severe aortic valve stenosis - Corrected Proof

2012-01-13

Objective: To evaluate whether myocardial fibrosis influences left ventricular performance in severe aortic stenosis and to assess its effect on long-term survival after aortic valve replacement.Methods: Myocardial fibrosis was evaluated in biopsy specimens taken from the interventricular septum in 99 patients undergoing aortic valve replacement because of severe or prevalent aortic stenosis. Clinical and echocardiographic evaluations were performed at a mean follow-up of 6.2 ± 3.0 years. The patients were classified according to the myocardial fibrosis severity (none or mild in 28, moderate in 52, and severe in 19).Results: Patients with severe myocardial fibrosis had a dilated left ventricle and positive association between the left ventricular end-diastolic diameter (R = 0.77, P < .001), left ventricular end-systolic diameter (R = 0.78, P < .001), left ventricular end-systolic wall stress (R = 0.74, P < .001) and the degree of myocardial fibrosis. Myocardial fibrosis was inversely related to left ventricular fractional shortening (R = −0.64, P < .001), left ventricular ejection fraction (R = −0.53, P < .001), and left ventricular relative wall thickness (R = −0.70, P < .001). Patients with a higher grade of myocardial fibrosis had a significantly lower freedom from cardiac death at 10 years (42% ± 19% vs 89% ± 6%, P = .002), with congestive heart failure the most common cause of death. At Cox regression analysis, patient age (P = .012), low preoperative transvalvular gradient less than 40 mm Hg (P = .040), preoperative end-systolic wall stress (P = .046), and preoperative myocardial fibrosis grade (P = .034) emerged as the strongest independent predictors of mortality.Conclusions: In patients with severe aortic valve stenosis, the amount of myocardial fibrosis appears to have significant effect on clinical status and long-term survival after aortic valve replacement. From these results, we believe that new strategies for the earlier detection of myocardial fibrosis are needed to achieve a better prognostic outcome.

Evolving progress in oncologic and operative outcomes for esophageal and junctional cancer: Lessons from the experience of a high-volume center - Corrected Proof

2012-01-13

Objective: Modern series from high-volume esophageal centers report an approximate 40% 5-year survival in patients treated with curative intent and postoperative mortality rates of less than 4%. An objective analysis of factors that underpin current benchmarks within high-volume centers has not been performed.Methods: Three time periods were studied, 1990 to 1998 (period 1), 1999 to 2003 (period 2), and 2004 to 2008 (period 3), in which 471, 254, and 342 patients, respectively, with esophageal cancer were treated with curative intent. All data were prospectively recorded, and staging, pathology, treatment, operative, and oncologic outcomes were compared.Results: Five-year disease-specific survival was 28%, 35%, and 44%, and in-hospital postoperative mortality was 6.7%, 4.4%, and 1.7% for periods 1 to 3, respectively (P < .001). Period 3, compared with periods 1 and 2, respectively, was associated with significantly (P < .001) more early tumors (17% vs 4% and 6%), higher nodal yields (median 22 vs 11 and 18), and a higher R0 rate in surgically treated patients (81% vs 73% and 75%). The use of multimodal therapy increased (P < .05) across time periods. By multivariate analysis, age, T stage, N stage, vascular invasion, R status, and time period were significantly (P < .0001) associated with outcome.Conclusions: Improved survival with localized esophageal cancer in the modern era may reflect an increase of early tumors and optimized staging. Important surgical and pathologic standards, including a higher R0 resection rate and nodal yields, and lower postoperative mortality, were also observed.

Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery - Corrected Proof

2012-01-13

Objective: Progression of functional tricuspid regurgitation is not uncommon after mitral valve surgery and is associated with poor outcomes. We tested the hypothesis that concomitant tricuspid valve annuloplasty in patients with tricuspid annulus dilatation (≥40 mm) prevents tricuspid regurgitation progression after mitral valve surgery.Methods: We enrolled 44 patients undergoing mitral valve surgery (both repair or replacement) showing less than moderate (≤+2) tricuspid regurgitation and dilated tricuspid annulus (≥40 mm) at preoperative echocardiography. They were randomized to receive (n = 22) or not receive (n = 22) concomitant tricuspid annuloplasty (Cosgrove–Edwards annuloplasty ring; Edwards Lifesciences, Irvine, Calif) at the time of mitral valve surgery. Clinical and echocardiographic follow-up was 100% completed at 12 months after surgery.Results: Preoperative clinical and echocardiographic characteristics were comparable in the 2 groups. Operative mortality was 4.4% (1 death in each group). At 12 months follow-up, tricuspid regurgitation was absent in 71% (n = 15) versus 19% (n = 4) of patients in the treatment and control groups, respectively (P = .001). Moderate to severe tricuspid regurgitation (≥+3) was present in 0% versus 28% (n = 6) of patients in the treatment and control groups, respectively (P = .02). Pulmonary artery systolic pressure significantly decreased from baseline in all cases (P < .001) and was comparable in the 2 groups (41 ± 8 mm Hg vs 40 ± 5 mm Hg; P = .4). Right ventricular reverse remodeling was marked in the treatment group (right ventricular long axis: 71 ± 7 mm vs 65 ± 8 mm; P = .01; short axis: 33 ± 4 mm vs 27 ± 5 mm; P = .001) but only minimal in the control group (right ventricular long axis: 72 ± 6 mm vs 70 ± 7 mm; P = .08; short axis: 34 ± 5 mm vs 33 ± 5 mm; P = .1). The 6-minute walk test improved from baseline in both groups (P < .001), but this improvement was greater in the treatment group (+115 ± 23 m from baseline vs +75 ± 35 m; P = .008).Conclusions: Prophylactic tricuspid valve annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular remodeling, and better functional outcomes.

Outcomes of less invasive J-incision approach to aortic valve surgery - Corrected Proof

2012-01-13

Objective: Less invasive approaches to aortic valve surgery are increasingly used; however, few studies have investigated their impact on outcome. We sought to compare clinical outcomes after these approaches with full sternotomy using propensity-matching methods.Methods: From January 1995 to January 2004, a total of 2689 patients underwent isolated aortic valve surgery, 1193 via upper J-hemisternotomy and 1496 via full sternotomy. Because of important differences in patient characteristics between these groups, a propensity score based on 42 variables was used to obtain 832 well-matched patient pairs (70% of possible cases).Results: In-hospital mortality was identical for propensity-matched patients, 0.96% (8 in each). Occurrences of stroke (P > .9), renal failure (P = .8), and myocardial infarction (P = .7) were similar. However, 24-hour mediastinal drainage was a third less after less invasive surgery (median, 250 vs 350 mL; P < .0001), and fewer patients received transfusions (24% vs 34%; P < .0001). More patients undergoing less invasive surgery were extubated in the operating room (12% vs 1.6%; P < .0001), postoperative forced 1-second expiratory volume was higher (P = .009), and fewer had respiratory failure (P = .01). Early after operation, pain scores were lower (P < .0001) after less-invasive surgery and postoperative length of stay shorter (P < .0001).Conclusions: Within that portion of the spectrum of isolated aortic valve surgery where propensity matching was possible, minimally invasive aortic valve surgery had not only cosmetic advantages, but blood product use, respiratory, pain, and resource utilization advantages over full sternotomy, and no apparent detriments. Less invasive aortic valve surgery should be considered for most aortic valve operations.

Discussion - Corrected Proof

2012-01-13

Dr W. Randolf Chitwood (Greenville, NC). In this study, you prospectively randomized 44 patients undergoing mitral surgery who had concomitant TR with a dilated annulus to receive or not receive a concomitant band annuloplasty. By preoperative echocardiography, each cohort had less than 2+ TR but a dilated annulus to more than 40 mm by echocardiography. At 12 months after surgery, the annuloplasty cohort had no TR and only 19% in the control group had no TR. The absence of TR was reflected in, as you said, reversed remodeling and improvement in patient functionality. On the basis of your data, you are suggesting that we perform prophylactic ringing of the TV.

Modified aortoplasty for discrete congenital supravalvular aortic stenosis - Corrected Proof

Matthew L. Stone, Ahmet Kilic, Irving L. Kron, James J. Gangemi — 2012-01-13

Congenital supravalvular aortic stenosis (SVAS) is a rare obstructive lesion of the left ventricular outflow tract, and novel surgical treatments have fostered improved outcomes and survival for children with this condition. We present here a successful 3-sinus patch reconstruction for SVAS with extended patch augmentation to the right coronary sinus of Valsalva, maintaining aortic root geometry and providing a simplified approach for ascending aortic augmentation at the right coronary sinus.

A simplified technique for total anomalous pulmonary venous connection repair associated with functional single ventricle - Corrected Proof

Naritaka Kimura, Ayumu Masuoka, Toshiyuki Katogi, Takaaki Suzuki — 2012-01-13

Surgical repair of total anomalous pulmonary venous connection (TAPVC) with single ventricle remains challenging because of the risk of late pulmonary venous obstruction. Since 2007, we have used the vertical vein to establish the continuity between the common atrium and the pulmonary vein without cutting into the pulmonary venous confluence. This report describes the outcome associated with this simplified technique for TAPVC repair.

The ethical dilemma of Thoracic Surgery recertification - Corrected Proof

Cary W. Akins — 2012-01-13

As stated in the published documents of the American Board of Thoracic Surgery (ABTS), “The primary purpose and most essential function of the Board is to protect the public by establishing and maintaining high standards in thoracic surgery.” Few would disagree that for initial certification, the ABTS has been successful. Indeed, in the current ABTS update published in this journal, the authors have outlined continuing process improvements, including alternate pathways to certification, revised case requirements that more accurately reflect current practice, and improved examination strategies. By all measures, ABTS initial certification of competency to the American public of an applicant, who has completed the necessary training and passed the current examination, to independently practice both general thoracic and cardiovascular branches of our specialty is accurate. However, I am not certain that the same degree of accuracy applies to recertification of all applicants who successfully complete the current ABTS Maintenance of Certification (MOS) process.

Effects of alcohol on pericardial adhesion formation in hypercholesterolemic swine - Corrected Proof

Antonio D. Lassaletta, Louis M. Chu, Frank W. Sellke — 2012-01-13

Objective: Reoperative cardiac surgery is complicated in part because of extensive adhesions encountered during the second operation. The purpose of this study was to examine the effects of alcohol with and without resveratrol (red wine vs vodka) on postoperative pericardial adhesion formation in a porcine model of hypercholesterolemia and chronic myocardial ischemia.Methods: Male Yorkshire swine were fed a high-cholesterol diet to simulate conditions of coronary artery disease followed by surgical placement of an ameroid constrictor to induce chronic ischemia. Postoperatively, control pigs continued their high-cholesterol diet alone, whereas the 2 experimental groups had diets supplemented with red wine or vodka. Seven weeks after ameroid placement, all animals underwent reoperative sternotomy.Results: Compared with controls, pericardial adhesion grade was markedly reduced in the vodka group, whereas there was no difference in the wine group. Intramyocardial fibrosis was significantly reduced in the vodka group compared with controls. There was no difference in expression of proteins involved in focal adhesion formation between any groups (focal adhesion kinase, integrin alpha-5, integrin beta-1, paxillin, vinculin, protein tyrosine kinase 2, protein kinase C ε, and phosphorylated protein kinase C ε). The wine group exhibited elevated C-reactive protein levels versus the control and vodka groups.Conclusions: Postoperative vodka consumption markedly reduced the formation of pericardial adhesions and intramyocardial fibrosis, whereas red wine had no effect. Analysis of protein expression did not reveal any obvious explanation for this phenomenon, suggesting a post-translational effect of alcohol on fibrous tissue deposition. The difference in adhesion formation in the vodka versus wine groups may be due to increased inflammation in the wine group.

Fifteen-year single-center experience with the Norwood operation for complex lesions with single-ventricle physiology compared with hypoplastic left heart syndrome - Corrected Proof

2012-01-13

Objective: The Norwood procedure, the first surgical step of staged palliation for hypoplastic left heart syndrome, is also applied for other complex single-ventricle lesions with systemic outflow tract obstruction or aortic arch hypoplasia. We reviewed our 15-year institutional experience with the Norwood procedure for patients with and without hypoplastic left heart syndrome.Methods: A total of 41 patients without hypoplastic left heart syndrome and 212 patients with hypoplastic left heart syndrome who underwent a Norwood procedure between January 1996 and December 2010 were enrolled. Full medical records were reviewed to assess the determinants of outcome.Results: Early failure (death or cardiac transplantation) was 7% in patients without hypoplastic left heart syndrome and 13% in patients with hypoplastic left heart syndrome (P = .29). Frequency of postoperative complications, duration of postoperative ventilation, and length of vasoactive drug treatment were not different between groups. Transplant-free survival until the second operative step trended to be higher for patients without hypoplastic left heart syndrome (92% vs 80%, P = .067). Recurrent aortic arch obstruction was more common in patients without hypoplastic left heart syndrome (15/39 vs 32/171, P = .008), but there were 4 patients with stenosis of the proximal aortic arch. In subsequent procedures, 31 patients without hypoplastic left heart syndrome underwent superior cavopulmonary anastomosis and 5 biventricular repair. Overall transplant-free survival was not different between groups (P = .119) but trended to be higher in patients with a systemic or substantial left ventricle remnant contributing to cardiac output (P = .082).Conclusions: Early and long-term survivals and postoperative complications were similar between patients with and without hypoplastic left heart syndrome undergoing a Norwood operation. Recurrent aortic arch obstruction was common in both groups but more prevalent in patients without hypoplastic left heart syndrome.

Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology - Corrected Proof

Robert James Cerfolio, Ayesha S. Bryant, Douglas J. Minnich — 2012-01-13

Objective: Thoracic surgeons are performing robotic resections for anterior mediastinal tumors; however, tumors located in the posterior and especially the inferior chest can be difficult to approach robotically. The objective of this study was to evaluate the efficacy of the robot for resection of these tumors.Methods: We performed a retrospective review of the evolution and outcomes of our surgical technique for inferior or posterior mediastinal pathology.Results: During a 30-month period, 153 patients underwent robotic surgery for pathology in the mediastinum, located in the inferior or posterior mediastinum in 75 of these patients. The most common indications for surgery were posterior mediastinal mass or lymph node in 41 patients, esophageal or bronchogenic cysts in 11 patients, esophageal leiomyoma in 7 patients, and diaphragmatic elevation in 7 patients. The median tumor size was 4.4 cm, and the median length of stay was 1 day. One patient was converted to thoracotomy, but no patients were converted for bleeding. Morbidity occurred in 9 patients (12%), major in 1 patient (a delayed esophageal leak after epiphrenic diverticulectomy). There was no mortality. Technical improvements included using robotic arm 3 posteriorly for retraction, side-docking, or coming over the back of the patient for tumors inferior to the inferior pulmonary vein and for diaphragmatic plication and using the lateral decubitus position for extraction of tumors larger than 3 cm via an access port over the tenth rib above the diaphragmatic fibers.Conclusions: The robot affords safe access using a completely portal approach for resection of and surgical intervention for inferior and posterior chest pathology and for anterior tumors. Specific techniques can be used to improve the operation.

Thoracic empyema in patients with liver cirrhosis: Clinical characteristics and outcome analysis of thoracoscopic management - Corrected Proof

2012-01-13

Objective: Thoracic empyema in cirrhotic patients is a challenging situation, and the clinical characteristics are rarely reported. The objective of this study was to report the clinical characteristics among this group and to evaluate whether thoracoscopic intervention would affect clinical outcomes.Methods: Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriologic studies, and treatment outcomes of 63 cirrhotic patients with thoracic empyema. A propensity-score based process, matched on age, sex, diabetes mellitus, malignancy, cause, and Child-Pugh classification (A, B, or C), was performed to equalize potential prognostic factors in thoracoscopy and nonthoracoscopy groups. The Kaplan–Meier curve and log-rank test were applied to compare the survival to discharge between the 2 matched groups.Results: The median patient age was 61 years. Thirty-two patients (51%) underwent thoracoscopic management, and the remaining patients underwent thoracocentesis or tube thoracostomy. The median hospital stay was 28 days, and 19 patients (30%) had in-hospital mortality. Multivariate analysis showed that Child-Pugh C disease and positive blood cultures were risk factors for in-hospital mortality (P = .016 and .027, respectively), whereas thoracoscopic management may be favorable for survival (P = .041). The propensity score–matched analysis showed a significant reduction in intensive care unit stay (P = .044) in the thoracoscopy group. Kaplan–Meier survival analysis revealed a higher survival to discharge, favoring thoracoscopy over non-thoracoscopy treatment (P = .035).Conclusion: Management of thoracic empyema in cirrhotic patients is complicated and associated with a high mortality. With proper patient selection, thoracoscopic management is feasible and may provide a better chance of survival.

Serum creatinine as a perioperative biomarker: A challenge for perioperative management and an opportunity for the Cardiothoracic Surgery Trials Network - Corrected Proof

John G. Augoustides — 2012-01-13

Despite recent advances, coronary artery bypass grafting (CABG) is still associated with adverse outcomes in patients with renal dysfunction both in the short term and in the long term, even when it is subclinical. Serum biomarkers, such as serum creatinine, enhance the identification of high-risk patients and thus may further facilitate targeting of interventions to optimize outcome after CABG. In fact, elevated serum creatinine has already been integrated into standard cardiac surgical risk calculators, such as the Society of Thoracic Surgeons PROM score and the EuroSCORE.

Association of feeding modality with interstage mortality after single-ventricle palliation - Corrected Proof

2012-01-13

Objective: Interstage mortality has been reported in 10% to 25% of hospital survivors after single-ventricle palliation. The purpose of this study was to examine the impact of feeding modality at discharge after single-ventricle palliation on interstage mortality.Methods: We conducted a retrospective review of all neonates undergoing single-ventricle palliation from January 2003 to January 2010. A total of 334 patients (90%) survived to hospital discharge, comprising the study group. Preoperative, operative, and postoperative variables were examined, including feeding method at discharge. Multivariate Poisson regression models were constructed to estimate the relative risk of interstage mortality.Results: Of 334 patients, 56 (17%) underwent gastrostomy tube ± Nissen. There was a statistically significant increase in interstage mortality for patients who underwent gastrostomy tube ± Nissen compared with patients who did not (relative risk, 2.38; 95% confidence interval, 1.05–5.40; P = .04]). Of the 278 patients who were not fed via a gastrostomy tube ± Nissen, 190 (68%) were fed with nasogastric feedings and 88 (32%) were fed entirely by mouth. There was no difference in interstage mortality between these 2 groups (relative risk, 0.92; 95% confidence interval, 0.31–2.73; P = .89).Conclusions: Neonates undergoing single-ventricle palliation who require gastrostomy tube ± Nissen are at an increased risk of interstage mortality. The need for gastrostomy tube ± Nissen in this population may be a marker for other unmeasured comorbidities that place them at an increased risk of interstage mortality. Discharge with nasogastric feeds does not increase the risk of interstage mortality.

Late remote ischemic preconditioning in children undergoing cardiopulmonary bypass: A randomized controlled trial - Corrected Proof

Marcos A. Pavione, Fabio Carmona, Margaret de Castro, Ana P.C.P. Carlotti — 2012-01-13

Objective: Cardiopulmonary bypass is associated with ischemia–reperfusion injury to multiple organs. We aimed to evaluate whether remote ischemic preconditioning performed the day before surgery for congenital heart disease with cardiopulmonary bypass attenuates the postoperative inflammatory response and myocardial dysfunction.Methods: This was a prospective, randomized, single-blind, controlled trial. Children allocated to remote ischemic preconditioning underwent 4 periods of 5 minutes of lower limb ischemia by a blood pressure cuff intercalated with 5 minutes of reperfusion. Blood samples were collected 4, 12, 24, and 48 hours after cardiopulmonary bypass to evaluate nuclear factor kappa B activation in leukocytes by quantification of mRNA of I kappa B alpha by real-time quantitative polymerase chain reaction and for interleukin-8 and 10 plasma concentration measurements by enzyme-linked immunosorbent assay. Myocardial dysfunction was assessed by N-terminal pro-B-type natriuretic peptide and cardiac troponin I plasma concentrations, measured by chemiluminescence, and clinical parameters of low cardiac output syndrome.Results: Twelve children were allocated to remote ischemic preconditioning, and 10 children were allocated to the control group. Demographic data and Risk Adjustment for Congenital Heart Surgery 1 classification were comparable in both groups. Remote ischemic preconditioning group had lower postoperative values of N-terminal pro-B-type natriuretic peptide, but cardiac troponin I levels were not significantly different between groups. Interleukin-8 and 10 concentrations and I kappa B alpha gene expression were similar in both groups. Postoperative morbidity was similar in both groups; there were no postoperative deaths in either group.Conclusions: Late remote ischemic preconditioning did not provide clinically relevant cardioprotection to children undergoing cardiopulmonary bypass.

Pulmonary reperfusion injury after the unifocalization procedure for tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collateral arteries - Corrected Proof

2012-01-13

Objective: The aims of our study are to describe the incidence, clinical profile, and risk factors for pulmonary reperfusion injury after the unifocalization procedure for tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collateral arteries. We hypothesized the following: (1) Pulmonary reperfusion injury is more likely to occur after unifocalization procedures in which a septated circulation is not achieved, (2) pulmonary reperfusion injury is directly related to the severity of stenosis in major aortopulmonary collateral arteries, and (3) pulmonary reperfusion injury leads to longer intubation time and longer hospitalization.Methods: Consecutive patients with tetralogy of Fallot/pulmonary atresia/major aortopulmonary collateral arteries who underwent unifocalization procedures over a 5-year period were identified in our institutional database. Chest radiographs before the unifocalization procedure, from postoperative days 0 to 4, and from 2 weeks after the unifocalization procedure or at discharge were evaluated by a pediatric radiologist for localized pulmonary edema. Determination of stenosis severity was based on review of preoperative angiograms. Statistical analyses using multivariate repeated-measures analyses were performed with generalized estimating equations.Results: Pulmonary reperfusion injury was present after 42 of 65 (65%) unifocalization procedures. In 36 of 42 cases of reperfusion injury, unilateral injury was present. Risk factors for the development of reperfusion injury included bilateral unifocalization (P = .01) and degree of stenosis (P = .03). We did not identify an association between pulmonary reperfusion injury and time to tracheal extubation or hospital discharge.Conclusions: Pulmonary reperfusion injury is common after the unifocalization procedure for tetralogy of Fallot/pulmonary atresia/major aortopulmonary collateral arteries. Severity of stenosis and bilateral unifocalization are associated with the development of reperfusion injury.

Impact of pressure load caused by right ventricular outflow tract obstruction on right ventricular volume overload in patients with repaired tetralogy of Fallot - Corrected Proof

2012-01-13

Objectives: In correction of tetralogy of Fallot (TOF), surgical strategies to minimize right ventricular outflow tract (RVOT) enlargement have recently been preferred. However, we may be confronted with residual pulmonary stenosis (PS) combined with pulmonary regurgitation (PR), and how the pressure load affects these patients is not evident.Methods: We compared 51 patients with PR and significant PS (PR with PS group) with 87 patients with PR without significant PS (PR group) using echocardiography and cardiac magnetic imaging. We evaluated the differences in parameters derived by magnetic resonance imaging between the 2 groups and the influence of the pressure load on right ventricular (RV) volume and function.Results: Although the PR fraction was similar between the 2 groups, the PR with PS group showed significantly smaller RV end-diastolic volume (136.7 ± 26.5 mL/m2 vs 151.2 ± 34.7 mL/m2; P = .01), RV end-systolic volume (68.1 ± 23.7 mL/m2 vs 80.2 ± 27.5 mL/m2; P = .01), and slightly better RV ejection fraction (51.1% ± 9.8% vs 47.6% ± 8.9%; P = .03) than the PR group. For influence of the pressure load, PR fraction (r = −0.18, P = .03), RV end-diastolic volume (r = −0.25, P = .003), and RV end-systolic volume (r = −0.24, P = .005) were decreased as peak pressure gradient of PS was higher. Linear regression analysis revealed that both PR fraction and peak pressure gradient of PS were independent predictors for RV volume.Conclusions: Our study demonstrated that the RV pressure load prevented RV dilatation from chronic PR without systolic dysfunction. It is suggested that a proper relief of RVOT obstruction with acceptable residual stenosis is more advantageous than aggressive RVOT enlargement in the long-term outcome of repaired TOF.

Prediction of left ventricular assist device implantation after repair of anomalous left coronary artery from the pulmonary artery - Corrected Proof

Frank Edwin, Robin H. Kinsley, Alexander Quarshie, Peter R. Colsen — 2011-12-22

Objective: We sought to determine the value of preoperative left ventricular function and cardiopulmonary bypass parameters in the prediction of left ventricular assist device implantation after repair of anomalous left coronary artery from the pulmonary artery.Methods: Multivariate logistic regression was performed to identify a predictive model for postrepair left ventricular assist device implantation using the records of 27 patients who underwent direct aortic implantation of anomalous left coronary artery from the pulmonary artery from 1994 to 2011.Results: Seven patients required left ventricular assist device implantation. Patients in group 1 (n = 20) were successfully weaned from cardiopulmonary bypass. Patients in group 2 (n = 7) required left ventricular assist device as a bridge to recovery. The 2 groups were similar in age, weight, and body surface area. Six of the 7 patients (85.7%) who required left ventricular assist device survived to hospital discharge. Hospital mortality was 3.7%. In the univariate model, fractional shortening, ejection fraction, and aortic crossclamp time were significantly associated with left ventricular assist device implantation (P = .026, .035, .031, respectively). In the multivariate analysis, the aortic crossclamp time was the only significant independent predictor of left ventricular assist device implantation. Aortic crossclamp time and fractional shortening together accounted for 80.9% (P < .001) of the variability in left ventricular assist device implantation and constituted the best predictive model: All patients requiring postrepair left ventricular assist device implantation had a fractional shortening less than 20% and an aortic crossclamp time greater than 56 minutes.Conclusions: The fractional shortening and aortic crossclamp time together predict 80.9% of the variability in postrepair left ventricular assist device implantation after repair of anomalous left coronary artery from the pulmonary artery. When preoperative left ventricular dysfunction is severe (fractional shortening < 20%), an aortic crossclamp time greater than 56 minutes is associated with a substantial risk of left ventricular assist device implantation after repair of anomalous left coronary artery from the pulmonary artery.

Invasive adenocarcinoma with bronchoalveolar features: A population-based evaluation of the extent of resection in bronchoalveolar cell carcinoma - Corrected Proof

2011-12-19

Objective: We used a population-based data set to assess the association between the extent of pulmonary resection for bronchoalveolar carcinoma and survival. The reports thus far have been limited to small, institutional series.Methods: Using the Surveillance, Epidemiology, and End Results database (1988–2007), we identified patients with bronchoalveolar carcinoma who had undergone wedge resection, segmentectomy, or lobectomy. The bronchoalveolar carcinoma histologic findings were mucinous, nonmucinous, mixed, not otherwise specified, and alveolar carcinoma. To adjust for potential confounders, we used a Cox proportional hazards regression model.Results: A total of 6810 patients met the inclusion criteria. Compared with the sublobar resections (wedge resections and segmentectomies), lobectomy conferred superior 5-year overall (59.5% vs 43.9%) and cancer-specific (67.1% vs 53.1%) survival (P < .0001). After adjusting for potential confounding patient and tumor characteristics, we found that patients who underwent an anatomic resection had significantly better overall (segmentectomy: hazard ratio, 0.59; 95% confidence interval, 0.43–0.81; lobectomy: hazard ratio, 0.50; 95% confidence interval, 0.44–0.57) and cancer-specific (segmentectomy: hazard ratio, 0.51; 95% confidence interval, 0.34–0.75; lobectomy: hazard ratio, 0.46; 95% confidence interval, 0.40–0.53) survival compared with patients who underwent wedge resection. Additionally, gender, race, tumor size, and degree of tumor de-differentiation were negative prognostic factors. Our results were unchanged when we limited our analysis to early-stage disease.Conclusions: Using a population-based data set, we found that anatomic resections for bronchoalveolar carcinoma conferred superior overall and cancer-specific survival rates compared with wedge resection. Bronchoalveolar carcinoma’s propensity for intraparenchymal spread might be the underlying biologic basis of our observation of improved survival after anatomic resection.

Contemporary results of open aortic arch surgery - Corrected Proof

Mathew Thomas, Zhuo Li, David J. Cook, Kevin L. Greason, Thoralf M. Sundt — 2011-12-19

Objectives: The success of endovascular therapies for descending thoracic aortic disease has turned attention toward stent graft options for repair of aortic arch aneurysms. Defining the role of such techniques demands understanding of contemporary results of open surgery.Methods: The outcomes of open arch procedures performed on a single surgical service from July 1, 2001 to August 30, 2010, were examined as defined per The Society of Thoracic Surgeons national database.Results: During the study period, 209 patients (median age, 65 years; range, 26-88) underwent arch operations, of which 159 were elective procedures. In 65 the entire arch was replaced, 22 of whom had portions of the descending thoracic aorta simultaneously replaced via bilateral thoracosternotomy. Antegrade cerebral perfusion was used in 78 patients and retrograde cerebral perfusion in 1. Operative mortality was 2.5% in elective circumstances and 10% in emergency cases (P = .04). The stroke rate was 5.0% when procedures were performed electively and 11.8% when on an emergency basis (P = .11). Procedure-specific mortality rates were 5.5% for elective and 10% for emergency procedures with total arch replacement, and 1.0% for elective and 10% for emergency procedures with hemiarch replacement. Stratified by extent, neurologic event rates were 5.5% for elective and 10% for emergency procedures with total arch and 4.8% for elective and 12.5% for emergency procedures with hemiarch replacement.Conclusions: Open aortic arch replacement can be performed with low operative mortality and stroke rates, especially in elective circumstances, by a team with particular focus on the procedure. The results of novel endovascular therapies should be benchmarked against contemporary open series performed in such a setting.