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Open in new tab Download slide Open in new tab Download slide OBJECTIVES Kommerell diverticulum (KD) is a rare congenital vascular anomaly often associated with an aberrant subclavian artery (ASCA). Definitive indications for intervention remain unclear. We present open and endovascular (EV) operative outcomes in a large contemporary series and propose a management algorithm. METHODS Between 2004 and 2020, 224 patients presented with ASCA and associated KD to our institution. Of the 43 (19.2%) patients who underwent operative repair, 31 (72.1%) had open surgical (OS) repair via thoracotomy and 12 (27.9%) had EV repair. Univariable and bivariable statistical analyses were conducted stratified by approach. The median follow-up time was 5.4 years (IQR, 2.9–9.7). RESULTS Patients in EV group were older (68 years vs 47 years, P  < 0.001) and had larger aneurysms (base diameter 3.2 cm vs 21.5 cm, P  = 0.007). All patients with dysphagia lusoria were treated with open surgery (n  = 20). Asymptomatic patients with incidentally detected KD (50% vs 16.1%), those with chest or back pain (50% vs 19.4%) and patients who presented with an aortic emergency (25% vs 6.5%) were more likely to be treated endovascularly (P  = 0.001). Carotid-to-subclavian bypass was used in 38 (88.4%) patients. There were no operative mortalities. In-hospital mortality was similar between groups (3.2% vs 16.7%, P  = 0.121). Mid-term mortality was higher in the EV group [4 (33.8%) vs 0, P  < 0.001]. There were 2 (15.4%) postoperative strokes in the EV group. There were no statistically significant differences in other postoperative complications or hospital length of stay between groups. CONCLUSIONS KD can be managed using open or EV approaches with low morbidity and mortality. Treatment strategy should depend on clinical presentation and patient factors. [ABSTRACT FROM AUTHOR]

The article presents the reports of Theodore Roosevelt on the evolution with modifications to improve long-term performance. Topics discussed include perioperative mortality for a young adult calculated from the Society of Thoracic Surgeons (STS) database Risk Calculator; mechanical valves failed to demonstrate superiority of the former valve; and the implantation of xenografts in a patient.

A response by Chan B. Park and Thoralf M. Sundt III to a letter to the editor about their article "What is the optimal myocardial preservation strategy at re-operation for aortic valve replacement in the presence of a patent internal thoracic artery?" in the 2011 issue is presented.

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 author reflects on a study related to postoperative glucose control which shows a disciplined approach to the "Plan-Do-Check-Act" cycle in glucose management.

Open in new tab Download slide Open in new tab Download slide OBJECTIVES We sought to examine management and outcomes of (Stanford) type A aortic dissection (TAAAD) in patients aged >70 years. METHODS All patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection database (1996–2018) were studied (n  = 5553). Patients were stratified by age and therapeutic strategy. Outcomes for octogenarians were compared with those for septuagenarians. Variables associated with in-hospital mortality were identified by multivariable logistic regression. RESULTS In-hospital mortality for all patients (all ages) was 19.7% (1167 deaths), 16.1% after surgical intervention vs 52.1% for medical management (P  <   0.001). Of the study population, 1281 patients (21.6%) were aged 71–80 years and 475 (8.0%) were >80 years. Fewer octogenarians underwent surgery versus septuagenarians (68.1% vs 85.9%, P  <   0.001). Overall mortality was higher for octogenarians versus septuagenarians (32.0% vs 25.6%, P  =   0.008); however, surgical mortality was similar (25.1% vs 21.7%, P  =   0.205). Postoperative complications were comparable between surgically managed cohorts, although reoperation for bleeding was more common in septuagenarians (8.1% vs 3.2%, P  =   0.033). Kaplan–Meier 5-year survival was significantly superior after surgical repair in all age groups, including septuagenarians (57.0% vs 13.7%, P  <   0.001) and octogenarians (35.5% vs 22.6%, P  < 0.001). CONCLUSIONS When compared with septuagenarians, a smaller percentage of octogenarians undergo surgical repair for TAAAD, even though postoperative outcomes are similar. Age alone should not preclude consideration for surgery in appropriately selected patients with TAAAD. [ABSTRACT FROM AUTHOR]

OBJECTIVE A number of factors limit the effectiveness of current aortic arch studies in assessing optimal neuroprotection strategies, including insufficient patient numbers, heterogenous definitions of clinical variables, multiple technical strategies, inadequate reporting of surgical outcomes and a lack of collaborative effort. We have formed an international coalition of centres to provide more robust investigations into this topic. METHODS High-volume aortic arch centres were identified from the literature and contacted for recruitment. A Research Steering Committee of expert arch surgeons was convened to oversee the direction of the research. RESULTS The International Aortic Arch Surgery Study Group has been formed by 41 arch surgeons from 10 countries to better evaluate patient outcomes after aortic arch surgery. Several projects, including the establishment of a multi-institutional retrospective database, randomized controlled trials and a prospectively collected database, are currently underway. CONCLUSIONS Such a collaborative effort will herald a turning point in the surgical management of aortic arch pathologies and will provide better powered analyses to assess the impact of varying surgical techniques on mortality and morbidity, identify predictors for neurological and operative risk, formulate and validate risk predictor models and review long-term survival outcomes and quality-of-life after arch surgery. [ABSTRACT FROM PUBLISHER]

Abstract: Objective: The optimal myocardial preservation strategy at re-operation for aortic valve replacement (AVR) after prior coronary artery bypass grafting (CABG) in the presence of a patent internal thoracic artery (ITA) remains undefined. Methods: Patients undergoing AVR after prior CABG at our institution between 1 January 1996 and 31 December 2007 were identified; operative notes and outcomes were reviewed. Results: Of 628 patients with prior CABG undergoing AVR with or without concomitant procedures, 427 patients had a patent ITA. In 390, management of the ITA was detailed in the operative note, including 251 in whom it was clamped and 139 in whom it was left uncontrolled. Groups were demographically similar, although re-operative CABG was more frequent in the clamped group (42% vs 23%, p <0.001). The operative mortality rate among those undergoing only AVR±CABG was 7.7% (19/246), while that for all cases was 10.8% (42/390), and was lower when the ITA was left uncontrolled both for AVR±CABG (4.1% vs 10.1%, p =0.08) and overall (7.2% vs 12.7%, p =0.09). By multivariate analysis, leaving the ITA uncontrolled appeared protective (odds ratio (OR) 0.46, p =0.08). There was no clear trend supporting an optimal perfusion temperature when the ITA was left uncontrolled. Conclusions: Efforts to control the patent ITA at re-operation for AVR after prior CABG increase risk of injury and may actually increase operative mortality rate compared with leaving this critical graft open and perfusing the heart. [Copyright &y& Elsevier]

Abstract: Background: Previous research has found teamwork failures to be strongly associated with the occurrence of surgical error. There have been few efforts to prospectively collect data regarding teamwork failures and technical errors in order to create interventions that would maximize teamwork effectiveness thereby minimizing technical error. Methods: Thirty-one cardiac surgical cases were prospectively observed by a trained human factors observer. Events were characterized according to human factors theory and included teamwork failures and technical errors. Surgical team structure was also evaluated in an effort to identify if it had an impact on surgical team performance. Results: A strong correlation (r =0.67, p <0.001) was recognized between the occurrence of technical error (n =155) and teamwork failures (n =178). Teamwork failures consisted of surgeon–technical team failures (n =90, 51%), procedural information failures (n =36, 20%), surgeon–anesthesiologist failures (n =27, 15%), surgeon–perfusionist failures (n =18, 10%), and failures due to handoffs (n =7, 4%). Teams made up of members that were familiar with the operating surgeon had significantly fewer total event failures (8.6±1.6 vs 22±3.1, p <0.0001) and teamwork failures (5.6±1.8 vs 15.4±1.9, p <0.0001) in comparison to those teams where the majority of members were unfamiliar with the operating surgeon. Conclusions: These results indicate that the process of cardiac surgery would benefit from interventions to improve teamwork and communication. Such interventions could include preoperative briefings, revised approach to structuring of operative teams to favor members that have gained familiarity with the operating surgeon, standardized communication practices, and postoperative debriefings. [Copyright &y& Elsevier]