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Open in new tab Download slide OBJECTIVES Patients undergoing surgical mitral valve repair (MVr) for degenerative mitral regurgitation are at risk of even late postoperative atrial fibrillation (AF). Left atrial (LA) function has been shown superior to LA volume in evaluating the risk of AF in diverse cardiac conditions. We therefore investigated the prognostic value of LA function and volume in predicting mid-to-late postoperative AF after MVr (>30 days postoperatively). METHODS We retrospectively identified all patients who underwent MVr for degenerative mitral regurgitation between 2012 and 2019 at our institution. Exclusion criteria were preoperative AF, concomitant procedures, re-operations, missing or insufficiently processable preoperative echocardiograms and missing follow-up. LA function and volume measurements were conducted using speckle-tracking strain echocardiographic analysis. Postoperative LA function was measured in a subgroup with sufficient postoperative echocardiograms. RESULTS We included 251 patients, of whom 39 (15.5%) experienced AF in the mid-to-late postoperative period. Reduced LA strain parameters and more than mild preoperative tricuspid regurgitation were independently associated with mid-to-late postoperative AF. LA volume index had no association with mid-to-late postoperative AF in univariable analysis and did not improve the performance of multivariable models. Patients with mid-to-late AF exhibited diminished improvement in LA function after surgery. CONCLUSIONS In MVr patients, LA function (but not volume) showed independent predictive value for mid-to-late postoperative AF. Including LA function into surgical decision-making and approach may identify patients who will benefit from earlier intervention with the aim to prevent irreversible LA damage with consequent risk of postoperative AF. [ABSTRACT FROM AUTHOR]

The geometrical details and biomechanical relationships of the mitral valve–left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation. [ABSTRACT FROM AUTHOR]

Background: Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery. Methods: All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC. Results: Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre‐ or intraoperative utilization of intra‐aortic balloon pump or catheter‐based assist devices (OR = 4.54), intraoperative transfusion requirement of >4 RBC units(OR = 2.47), and cardiopulmonary bypass > 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC. Conclusions: We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above‐identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team. [ABSTRACT FROM AUTHOR]

Introduction: Intra-Aortic Balloon Pumps (IABPs) can be utilized to provide hemodynamic support in high risk patients awaiting coronary artery bypass grafting (CABG). There are many indications for IABP and institutional practice patterns regarding the placement of IABPs is variable. As a result, the preoperative placement of an IABP in a patient awaiting CABG is not standardized and may vary according to non-clinical factors. We hypothesize that the rate of IABP placement varies by day of the week.Methods: A retrospective cohort analysis of the Office of Statewide Health Planning and Development database from 2006 to 2010 was performed. All patients admitted for CABG were included. Patients who died within 24 h of admission and those who had absolute contraindications to IABP placement were excluded. The primary outcome was preoperative IABP placement versus non-placement. A multivariable logistic regression analysis to identify predictors of IABP placement was performed, adjusting for patient demographics, clinical factors, and system variables.Results: A total of 46,347 patients underwent CABG, of which 7695 (16.60%) had an IABP placed preoperatively. On unadjusted analysis, IABP rates were significantly higher on weekends versus weekdays (20.83% vs. 15.70%, p < 0.001). On adjusted analysis, patients awaiting CABG were 1.30 times more likely to have an IABP placed on weekends than on weekdays (OR: 1.30, 95% CI 1.20-1.40, p < 0.001).Conclusion: The odds of preoperative IABP placement prior to CABG is significantly increased on weekends compared to weekdays, even when controlling for clinical factors. Further exploration of this phenomenon and its associations are warranted. [ABSTRACT FROM AUTHOR]

Background: Donor sequence number (DSN) represents the number of recipients to whom an organ has been offered. The impact of seeing numerous prior refusals may potentially influence the decision to accept an organ. We sought to determine if DSN was associated with inferior posttransplant outcomes.Methods: Using the United Network for Organ Sharing database, a retrospective analysis was performed on 22 361 patients who received a lung transplant between 2005 and 2017. Patients were grouped into low DSN (1-24, n = 16 860) and high DSN (>24, n = 5501) categories. Baseline characteristics and posttransplant outcomes were analyzed. An institutional subgroup was also analyzed to compare rates of primary graft dysfunction (PGD) posttransplant.Results: The DSN ranged from 1 to 1735 (median, 7; interquartile range, 2-24). A total of 18 507 recipients received an organ with at least one prior refusal. Recipients of donors with a higher DSN were older (58 vs 55 years; P < .01) but had lower lung allocation scores (43.5 vs 47.5; P < .01). On adjusted analysis, high DSN was not associated with increased mortality (hazard ratio, 0.99; 95% confidence interval, 0.94-1.04; P = .77). There was no difference in the incidence of graft failure (P = .37) or retransplantation (P = .24). Recipient subgroups who received donors with an increasing DSN >50 and >75 also demonstrated no difference in mortality when compared with a low DSN (P = .86 and P = .97). There was no difference in PGD for patients with a low vs a high DSN at any time posttransplant.Conclusions: DSN is not associated with increased mortality in patients undergoing lung transplantation and should not negatively influence the decision to accept a lung for transplant. [ABSTRACT FROM AUTHOR]

Introduction Postoperative acute kidney injury (AKI) is a common complication in cardiac surgery. Levels of intravascular haemolysis are strongly associated with postoperative AKI and with prolonged (>90 min) use of cardiopulmonary bypass (CPB). Ferrous plasma haemoglobin released into the circulation acts as a scavenger of nitric oxide (NO) produced by endothelial cells. Consequently, the vascular bioavailability of NO is reduced, leading to vasoconstriction and impaired renal function. In patients with cardiovascular risk factors, the endothelium is dysfunctional and cannot replenish the NO deficit. A previous clinical study in young cardiac surgical patients with rheumatic fever, without evidence of endothelial dysfunction, showed that supplementation of NO gas decreases AKI by converting ferrous plasma haemoglobin to ferric methaemoglobin, thus preserving vascular NO. In this current trial, we hypothesised that 24 hours administration of NO gas will reduce AKI following CPB in patients with endothelial dysfunction. Methods This is a single-centre, randomised (1:1) controlled, parallel-arm superiority trial that includes patients with endothelial dysfunction, stable kidney function and who are undergoing cardiac surgery procedures with an expected CPB duration >90 min. After randomisation, 80 parts per million (ppm) NO (intervention group) or 80 ppm nitrogen (N2, control group) are added to the gas mixture. Test gases (N2 or NO) are delivered during CPB and for 24 hours after surgery. The primary study outcome is the occurrence of AKI among study groups. Key secondary outcomes include AKI severity, occurrence of renal replacement therapy, major adverse kidney events at 6 weeks after surgery and mortality. We are recruiting 250 patients, allowing detection of a 35% AKI relative risk reduction, assuming a two-sided error of 0.05. Ethics and dissemination The Partners Human Research Committee approved this trial. Recruitment began in February 2017. Dissemination plans include presentations at scientific conferences, scientific publications and advertising flyers and posters at Massachusetts General Hospital. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Outcomes of cardiac transplantation in patients undergoing reoperative sternotomy are often worse than primary transplants. However, the risks imposed by a prior sternotomy, left ventricular assist device (LVAD) or retransplantation have not been independently analysed. METHODS Using the United Network for Organ Sharing (UNOS) database, a retrospective propensity-matched cohort analysis was performed on 14 730 patients who received a heart transplant between 2005 and 2017. Of 7365 patients who underwent a reoperative sternotomy, 4526 (61%) patients had previous cardiac surgery, 2364 (32%) patients had an LVAD and 475 (6%) patients had a previous transplant. Baseline characteristics were compared, and survival was analysed using a Cox model. RESULTS Compared to patients who underwent a primary transplant, patients with a prior sternotomy had a worse long-term survival (P  < 0.001). There was no significant difference in survival between patients who had an LVAD and those who had a previous cardiac operation. However, all subgroups had better survival compared to patients who underwent a retransplant (P  < 0.05). On the multivariable analysis, prior sternotomy and radiation demonstrated an increased risk of death compared to primary transplants [prior cardiac surgery: hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.05–1.22; P  = 0.001; LVAD: HR 1.19, 95% CI 1.08–1.32; P  = 0.001; retransplant: HR 1.68, 95% CI 1.42–1.99; P  < 0.001; radiation: HR 1.82, 95% CI 1.00–3.30; P  = 0.04]. When excluding patients who died in the first year, there were no significant differences in survival between the primary transplant, prior cardiac surgery, LVAD and retransplant groups. CONCLUSIONS Prior sternotomy is a risk factor for worse survival after cardiac transplantation, mainly due to increased early postoperative mortality. A history of prior transplant confers the greatest risk compared to those who received an LVAD or had prior cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Structural valve deterioration (SVD) is a known limitation of bioprosthetic valves. Recent reports have suggested a concerning rate of early SVD in patients receiving a Mitroflow aortic bioprosthesis. We therefore compared the incidence of SVD and SVD requiring reoperation among patients receiving a Mitroflow versus a common contemporary bioprosthesis.Methods: A retrospective cohort analysis was performed on 592 patients receiving a Mitroflow aortic bioprosthesis at our institution between 2010 and 2014. Patients were matched 1:1 using a coarsened exact matching algorithm with patients receiving a Carpentier-Edwards Magna Ease aortic bioprosthesis (Edwards Lifesciences, Irvine, CA) during the same period. The incidence of SVD (defined as a mean transprosthetic gradient ≥30 mmHg or moderate to severe intraprosthetic regurgitation), reoperation for SVD, and cumulative survival were compared between prosthesis types.Results: The cumulative incidence of SVD at 5 years for all patients receiving a Mitroflow aortic bioprosthesis was 16% (13-21%) and 5% underwent reoperation for SVD. Implantation of a Mitroflow valve was associated with an increased risk of SVD compared to the comparator valve (hazard ratio [HR] 2.59 [1.69-3.98], P < 0.01). Older age had a protective effect against SVD (HR 0.95 [0.93-0.96], P < 0.01). Patients who received a Mitroflow valve had reduced long-term survival compared to those who received a comparator valve (P = 0.03).Conclusion: The Mitroflow aortic bioprosthesis is associated with increased rates of early SVD and reoperation for valvular dysfunction as well as reduced survival compared to a contemporary valve. Enhanced clinical and echocardiographic follow-up is advisable after Mitroflow implantation. [ABSTRACT FROM AUTHOR]

Background: There is a 30-60% incidence of recurrent mitral regurgitation (MR) after mitral valve annuloplasty (Ring) for secondary MR. A concomitant papillary muscle sling (Ring+Sling) may improve valve repair by providing a more physiologic geometry of the mitral apparatus.Methods: We retrospectively identified 58 consecutive patients with moderate-to-severe secondary MR who underwent a Ring+Sling repair, between March 2008 and May 2015. A Ring+Sling consisted of combined annuloplasty and papillary muscle approximation, utilizing a 4-mm polytetrafluoroethylene graft placed around the base of each muscle. Comparison of echocardiographic variables with patients who underwent a Ring only was performed utilizing 2:1 propensity-score matching (Ring+Sling = 34; Ring = 17).Results: The baseline demographics were similar between the groups. The mean time to follow-up echocardiogram was 10.1 months (range 0.25-42 months). At follow-up, a Ring+Sling repair was associated with a lower mitral valve tenting height (p = 0.005), mitral valve tenting area (p = 0.009), and interpapillary muscle distance (p = 0.001); a smaller posterior leaflet tethering angle (p = 0.003); and a greater leaflet coaptation length (p = 0.002), when compared with Ring only. Recurrence of moderate or greater MR occurred significantly less in the Ring+Sling group (14.7%), as compared with Ring only (35.3%) (p < 0.001). Finally, actuarial survival at three years was 87% for Ring+Sling, and 82% for Ring only (p = 0.49).Conclusions: A Ring+Sling for secondary MR results in favorable changes in the mitral valve apparatus geometry, and is associated with less MR recurrence in the early postoperative period. Longer-term follow-up is needed to assess its durability and effects on left ventricular remodeling and survival. [ABSTRACT FROM AUTHOR]

There is a growing demand from patients and referring physicians for minimally invasive cardiac surgery. Minimally invasive cardiac procedures are technically unique from conventional cardiac procedures and require a thorough understanding of the surgical, anesthetic, and perfusion strategies. Strategies include routine use of augmented venous drainage, alternative arterial and venous cannulation sites, and special cannulas designed for minimally invasive procedures. The following review describes the strategies and safety systems that should be considered when performing minimally invasive cardiac surgery. [ABSTRACT FROM PUBLISHER]

Objective: Thoracic epidural analgesia provides effective pain control after lung transplantation; however, the optimal timing of placement is controversial. We sought to compare pain control and pulmonary and epidural morbidity between patients receiving preoperative vs postoperative epidurals. Methods: Institutional records were reviewed for patients undergoing a bilateral lung transplant via a bilateral anterior thoracotomy with transverse sternotomy incision between January 2014 and January 2017. Pain control was measured using visual analog scale pain scores (0‐10). Pulmonary complications included a composite of pneumonia, prolonged intubation, and reintubation/tracheostomy. Results: Among 103 patients, 72 (70%) had an epidural placed preoperatively and 31 (30%) had an epidural placed within 72 hours posttransplant. There were no differences in the rates of cardiopulmonary bypass (3% vs 0%, P = 0.59); however, patients with a preoperative epidural were less likely to be placed on extracorporeal membrane oxygenation intraoperatively (25% vs 52%, P = 0.01). Pain control was similar at 24 hours (1.2 vs 1.7, P = 0.05); however, patients with a preoperative epidural reported lower pain scores at 48 (1.2 vs 2.1, P = 0.02) and 72 hours posttransplant (0.8 vs 1.7, P = 0.02). There were no differences in primary graft dysfunction (42% vs 56%, P = 0.28), length of mechanical ventilation (19.5 vs 24 hours, P = 0.18), or adverse pulmonary events (33% vs 52%, P = 0.12). No adverse events including epidural hematoma, paralysis, or infection resulted from epidural placement. Conclusion: Preoperative thoracic epidural placement provides improved analgesia without increased morbidity following lung transplantation. [ABSTRACT FROM AUTHOR]