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Background Mitral valve replacement in the setting of severe mitral annular calcification remains a surgical challenge. Transcatheter mitral valve replacement (TMVR) using an aortic balloon-expandable transcatheter heart valve is emerging as a potential treatment option for high surgical risk patients. Transseptal, transapical, or transatrial access is not always feasible, so an understanding of alternative implantation techniques is important. Objectives The authors sought to present a step-by-step description of a contemporary transatrial TMVR technique using balloon-expandable aortic transcatheter heart valves. This procedure has evolved over time to address valve migration, left ventricular outflow tract obstruction, and paravalvular leak. The authors present a refined technique that has been associated with the most reproducible outcomes. Methods A step-by-step description of the TMVR technique and outcomes of 8 patients treated using this technique are described. Baseline patient clinical and echocardiographic characteristics and 30-day post-TMVR outcomes are presented. Results Eight patients underwent transatrial TMVR at a single institution. Five had previous cardiac surgery. Mean STS score was 8%. Technical success by MVARC (Mitral Valve Academic Research Consortium) criteria was 100%. There was zero in-hospital and 30-day mortality. Procedural success by MVARC criteria at 30 days was 100%. Paravalvular leak immediately post-implant was none or trace in 6 and mild in 1. Conclusions The technique described is reproducible and was associated with favorable outcomes in this early experience. It represents a useful technique for the treatment of mitral valve disease in the setting of severe annular calcification. A structured and defined implantation technique is critical to investigators as this field evolves.

Teaching the next generation operative cardiac surgery while maintaining the highest level of patient care is an ever-increasing challenge given the growing proportion of patients with multiple comorbidities, the loss of more straightforward cases to percutaneous interventions, and the pressure of public reporting. No study to date has compared the outcomes of similar cases performed entirely ("skin-to-skin") by the resident with those performed entirely by the staff to confirm the safety of this practice.A total of 100 consecutive cardiac cases performed skin-to-skin by the resident (group R) were matched by procedure 1:1 to nonconsecutive cases performed by a single attending surgeon (group A). Patients were excluded from the analysis if there was overlap in any portion of the procedure by the trainee or the attending.Patients in group A were similar to those in group R with respect to age, gender, body mass index, American Society of Anesthesiologists classification, left ventricular ejection fraction, and diabetes mellitus. Mean operative times were longer in group R (4.6 vs 2.7 hours, P .001), as were cardiopulmonary bypass times (96 vs 50 minutes, P .001) and aortic crossclamp times (78 vs 39 minutes, P .001). There were no significant differences in red blood cell transfusions, reexplorations, stroke, length of stay, or wound infections. There were no in-hospital or 30-day deaths.Our data indicate that trainees can be educated in operative surgery under the current paradigm, despite longer operative times, without sacrificing outcome quality. It is reasonable to expect academic programs to continue providing trainees significant experience as primary operating surgeons.

There is growing concern over the impact of fatigue and long work hours on patient safety. Our objective was to determine the perioperative outcomes and hospital costs associated with starting nonemergent cardiac surgical cases after 3 pm.A retrospective analysis was performed on adult patients who underwent elective coronary artery bypass or valve surgery at our institution between July 2011 and March 2018. Cases were defined as "late start" if the incision time was after 3 pm. Postoperative outcomes, 30-day mortality, and total hospital costs were compared between propensity-matched samples of early-starting and late-starting cases.Of 2463 elective cases, 352 (14%) started after 3 pm. In propensity-matched samples, patients who had a late start demonstrated no difference in 30-day mortality (1% vs1%; P = .10) or postoperative complications, such as prolonged ventilation (5% vs 7%; P = .37), renal failure (2% vs 1%), or stroke (2% vs 1%; P = .23) compared with patients who had an early start. A late start did not impact the median duration of ventilation (4 vs 5 hours; P = .72), intensive care unit (ICU) length of stay (26 vs 22 hours; P = .28), or postoperative length of stay (6 vs 7 days; P = .37). In addition, there were no significant differences in total hospital cost (P = .09), operating room cost (P = .22), or ICU cost (P = .05).We report no differences in perioperative outcomes, operative mortality, length of stay, or total hospital cost for elective cases that start after 3 pm. This may be attributable to the resources available at a large quaternary center regardless of time of day.

Objectives Prolonged cardiopulmonary bypass (CPB) is recognized as a risk factor for acute renal failure (ARF), but the dose effect of time on bypass is unknown. We therefore examined the risk of ARF associated with increasing CPB time stratified by preoperative renal function. Methods A retrospective analysis was performed on 3889 patients undergoing cardiac surgery on CPB without circulatory arrest between 2011 and 2017 excluding those with a diagnosis of dialysis-dependent renal failure and those who had an intra-aortic balloon pump. Postoperative ARF was defined as a 3-fold increase in creatinine level, creatinine level > 4 mg/dL, or requirement for dialysis. A logistic regression model was built to identify predictors of ARF and to determine the probability of ARF. Results Postoperative ARF occurred in 72 patients (2%) overall. Of 100 patients with an estimated glomerular filtration rate Conclusions Increasing CPB duration is associated with postoperative ARF, particularly among those with preoperative renal impairment. For patients with an estimated glomerular filtration rate

Patients undergoing surgical aortic valve replacement (SAVR) are at risk of developing prolonged atrial fibrillation (AF) after surgery. Prophylactic interventions such as left atrial appendage amputation (LAAA) and pulmonary vein isolation (PVI) impose cost and operative risk, discouraging routine use. To guide such interventions, we investigated preoperative predictors of AF.A retrospective analysis was performed on patients undergoing SAVR between 2011 and 2017. Patients were excluded if they had a preoperative history of AF or underwent a LAAA or PVI. Baseline characteristics were compared between those who did and did not develop prolonged postoperative AF. Predictors of prolonged AF were identified using multivariable logistic regression.Of 720 patients identified, 170 (25%) developed prolonged (beyond 30 days) AF. Compared with patients who did not develop AF, those who developed prolonged AF were older (70.1 vs 62.4 years, P .001), had a greater incidence of hypertension (78% vs 61%, P .001), and were less likely to smoke (16% vs 31%, P .01). On multivariable regression, older age (odds ratio, 1.05; P .01) and left atrial enlargement (odds ratio, 1.66; P = .04) were predictors of prolonged AF. In this high-risk cohort, the incidence of prolonged postoperative AF was 40%.Older age and left atrial enlargement identify a stratum of patients at high risk of developing prolonged postoperative AF after SAVR. Multicenter, prospective studies should investigate the value of prophylactic interventions such as LAAA, Cox maze, or PVI in these individuals to obviate the consideration of late anticoagulation.

With increasing prevalence of injected drug use in the United States, a growing number of intravenous drug users (IVDUs) are at risk for infective endocarditis (IE) that may require surgical intervention; however, few data exist about clinical outcomes of these individuals.We evaluated consecutive adult patients undergoing surgery for active IE between 2002 and 2014 pooled from 2 prospective institutional databases. Death and valve-related events, including reinfection or heart valve reoperation, thromboembolism, and anticoagulation-related hemorrhage were evaluated.Of the 436 patients identified, 78 (17.9%) were current IVDUs. The proportion of IVDUs increased from 14.8% in 2002 to 2004 to 26.1% in 2012 to 2014. IVDUs were younger (aged 35.9 ± 9.9 years vs 59.3 ± 14.1 years) and had fewer cardiovascular risk factors than non-IVDUs. During follow-up (median, 29.4 months; quartile 1-3, 4.7-72.6 months), adverse events among all patients included death in 92, reinfection in 42, valve-reoperation in 35, thromboembolism in 17, and hemorrhage in 16. Operative mortality was lower among IVDUs (odds ratio, 0.25; 95% confidence interval [CI], 0.06-0.71), but overall mortality was not significantly different (hazard ratio [HR], 0.78; 95% CI, 0.44-1.37). When baseline profiles were adjusted by propensity score, IVDUs had higher risk of valve-related complications (HR, 3.82; 95% CI, 1.95-7.49; P .001) principally attributable to higher rates of reinfection (HR, 6.20; 95% CI, 2.56-15.00; P .001).The proportion of IVDUs among surgically treated IE patients is increasing. Although IVDUs have lower operative risk, long-term outcomes are compromised by reinfection.

Background Surgical dogma suggests that homografts should be used preferentially, compared with conventional xenograft or mechanical prostheses, in the setting of infective endocarditis (IE), because they have greater resistance to infection. However, comparative data that support this notion are limited. Methods From the prospective databases of 2 tertiary academic centers, we identified 304 consecutive adult patients (age ≥17 years) who underwent surgery for active IE involving the aortic valve (AV), in the period 2002 to 2014. Short- and long-term outcomes were evaluated using propensity scores and inverse-probability weighting to adjust for selection bias. Results Homografts, and xenograft and mechanical prostheses, were used in 86 (28.3%), 139 (45.7%), and 79 (26.0%) patients, respectively. Homografts were more often used in the setting of prosthetic valve endocarditis (58.1% vs 28.8%, P = .002) and methicillin-resistant Staphylococcus (25.6% vs 12.1%, P = .002), compared with conventional prostheses. Early mortality occurred in 17 (19.8%) in the homograft group, and 20 (9.2%) in the conventional group ( P = .019). During follow-up (median: 29.4 months; interquartile-range: 4.7-72.6 months), 60 (19.7%) patients died, and 23 (7.7%) experienced reinfection, with no significant differences in survival ( P = .23) or freedom from reinfection rates ( P = .65) according to the types of prostheses implanted. After adjustments for baseline characteristics, using propensity-score analyses, use of a homograft did not significantly affect early death (odds ratio 1.61; 95% confidence interval [CI], 0.73-3.40, P = .23), overall death (hazard ratio 1.10; 95% CI, 0.62-1.94, P = .75), or reinfection (hazard ratio 1.04; 95% CI, 0.49-2.18, P = .93). Conclusions No significant benefit to use of homografts was demonstrable with regard to resistance to reinfection in the setting of IE. The choice among prosthetic options should be based on technical and patient-specific factors. Lack of availability of homografts should not impede appropriate surgical intervention.

Objective Barlow's disease remains a challenging surgical pathology in patients presenting with mitral regurgitation. We reviewed our early and long-term results for patients with Barlow's disease who underwent minimally invasive mitral valve surgery. Methods Between 1999 and 2010, 145 patients with Barlow's disease underwent minimally invasive mitral valve repair at Leipzig Heart Center. Preoperative echocardiography and intraoperative valve analysis confirmed annular dilatation, bileaflet prolapse, and excessive leaflet tissue in all cases. We retrospectively reviewed mitral valve repair techniques, early and late postoperative clinical outcomes, and follow-up echocardiographic data. Results Successful mitral valve repair was performed in 94.5% of patients (n = 137), initial mitral valve replacement was performed in 2.8% of patients (n = 4), and mitral valve replacement after unsuccessful mitral valve repair was performed in 2.8% of patients (n = 4). Mean aortic crossclamp time was 99 ± 33 minutes, cardiopulmonary bypass time was 153 ± 47 minutes, and total duration of surgery was 200 ± 44 minutes. Mitral valve repair techniques consisted of ring annuloplasty and a variety of other methods (not mutually exclusive): "loop" neochordae (72% of patients), posterior mitral leaflet resection (28%), Alfieri stitch (17%), commissural plication (9%), chordal transfer (9%), and anterior mitral leaflet resection (7%). Concomitant procedures consisted of cryoablation for atrial fibrillation (28%), tricuspid valve repair (6%), and closure of an atrial septal defect/patent foramen ovale (12%). Thirty-day mortality was 1.4% (n = 2), rethoracotomy for bleeding was required in 4.1% of patients (n = 6), and conversion to sternotomy was required in 1 patient (0.7%). Long-term clinical follow-up was obtained in 100% of patients, and long-term echocardiographic data were obtained in 93.3% of surviving patients. Long-term survival was 94.7% ± 2.2% at 5 years and 88.3% ± 4.9% at 10 years. Freedom from mitral valve reoperation was 96.8% ± 1.6% at 5 years and 93.8% ± 2.6% at 10 years. Freedom from greater than 2+ grade mitral regurgitation was 90.2% ± 3.4% at 5 years and 88.4% ± 3.9% at 10 years. Conclusions A wide variety of repair techniques can be used to perform successful minimally invasive mitral valve repair in the majority of patients with Barlow's disease, with good early and long-term results.