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Early distal migration after transcatheter aortic valve replacement is a rare but potentially catastrophic complication that presents unique technical challenges for subsequent surgical management. This report describes a case of early distal migration of a Medtronic CoreValve Evolut R bioprosthesis (Minneapolis, MN) causing myocardial infarction from coronary ostial obstruction and provides a practical technique for open surgical device explantation and aortic valve re-replacement. Snaring the stent of the device using standard instruments is a simple but effective method for transcatheter aortic valve replacement explant that allows for optimal positioning of a single aortotomy at the standard anatomic site to facilitate subsequent surgical aortic valve replacement., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We have previously demonstrated that cardiac surgery trainees can safely perform operations "skin-to-skin" with adequate attending surgeon supervision., Methods: We used 100 consecutive cases (82 coronary artery bypass grafts, 9 aortic valve replacements, 7 coronary artery bypass grafts plus aortic valve replacements, 2 others) performed by residents (group R) to match 1:1 by procedure to nonconsecutive cases done by a single attending surgeon (group A) from July 2014 to October 2016. Patients were stratified based on whether the attending surgeon or trainee performed every critical step of the operation skin-to-skin. Outcomes included death, major morbidity, and readmission., Results: Patients in the two groups were similar with respect to demographic characteristics and comorbidities. The median follow-up time for patients in this study was 28 months (interquartile range: 23 to 35 months). There were seven deaths (3.5%; four in group A, three in group R, p = 0.7). Of the 43 patients (21.5%) who were readmitted during the study term, 27 patients (13.5%) were readmitted for causes related to the operation (11 in group A, 16 in group R, p = 0.02). The most common reasons for readmissions related to the operation were chest pain (n = 11), pleural effusion that required drainage (n = 8), pneumonia (n = 4), and unstable angina that required percutaneous coronary intervention (n = 3). No statistically significant differences were found in reasons for readmission between group A and group R., Conclusions: The equivalence of postoperative outcomes previously demonstrated at 30 days persists at midterm follow-up. Our data indicate that trainees can be educated in operative cardiac surgery under the current paradigm without sacrificing outcome quality. It is reasonable to expect academic programs to continue providing trainees with experience as primary operating surgeons., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Recent studies have suggested increased renal complications and long-term mortality with aprotinin use in coronary artery bypass grafting (CABG) patients. However, these studies have been criticized for including multiple centers and different dosing strategies. We analyzed prospectively collected registry data from a single center hospital utilizing a full-dose aprotinin regimen to evaluate if aprotinin was associated with increased mortality and adverse outcomes compared with Amicar., Methods: Data were prospectively collected from 1994 to 2006 at a teaching hospital. Long-term mortality was collected from a Social Security database. To account for differences between aprotinin and Amicar-treated patients, a propensity score was generated and propensity-stratified multivariate model for mortality were performed., Results: Compared with Amicar-treated patients (n = 1,830), aprotinin-treated patients (n = 1,507) were older, more often female, had lower creatinine clearance, and more baseline risk factors. Blood loss was lower in aprotinin-treated patients (median 715 mL vs 918 mL, p < 0.001). Postoperative renal failure was significantly higher in aprotinin patients (6.2% vs 2.7%, p < 0.001). At median 5.4-year follow-up (up to 12.2 years), aprotinin-treated patients had higher mortality versus Amicar-treated patients (Kaplan-Meier failure rates 43.5% vs 23.7% at 8 years, p < 0.0001). In a propensity-stratified model with multivariate adjustment, aprotinin remained associated with increased mortality (hazard ratio 1.62, 95% CI 1.39 to 1.90, p < 0.001). There was a stepwise relationship between weight-based aprotinin dose and mortality (p-trend < 0.001)., Conclusions: Among patients undergoing CABG in this registry, aprotinin use was associated with increased renal failure and higher mortality through 12 years in a propensity-stratified analysis. The increased mortality may be related to higher concentrations of aprotinin received.

Background: Barrett's esophagus, high-grade dysplasia (HGD), and invasive cancer are steps in the progression of esophageal adenocarcinoma. While surgery is recommended for resectable invasive adenocarcinoma, a number of treatment modalities are advocated for HGD. The purpose of this study is to determine the outcomes after surgery for HGD., Methods: We identified cases of HGD based on endoscopic biopsy in a single institution's databases from 1980 through 2001. Records were reviewed for patient characteristics, treatments, staging, and outcomes., Results: In a 22-year period, 869 cases of esophageal adenocarcinoma and 1,614 cases of Barrett's esophagus were diagnosed. Of these, 115 had HGD without pretreatment evidence of invasion. Forty-nine patients with HGD underwent resection (mean age, 59 years) as initial treatment. Forty-seven had endoscopic treatment (mean age, 70 years) by photodynamic therapy or endoscopic mucosal resection. Seven of the endoscopically treated patients failed, with three undergoing surgery and four observation. Nineteen patients were initially observed, with six eventually having surgery. For the 49 initially treated surgically, one (2%) operative mortality occurred. Invasive adenocarcinoma was present in 18 (37%). The five-year survival was 83% for all resected HGD patients (91% for those without invasion, 68% with invasion). Three of the eight deaths in those with invasion were from recurrent adenocarcinoma., Conclusions: Surgical resection of esophageal HGD can be performed with low mortality and allows long-term survival. A significant percentage with an initial diagnosis of HGD will have invasive disease at resection. Surgery is the optimal treatment for HGD unless contraindicated by severe comorbidities.

Background: Cold cardioplegia can induce rapid cooling contracture. The relations of cardioplegia-induced cooling contracture to myocardial temperature or myocyte calcium are unknown., Methods: Twelve crystalloid-perfused isovolumic rat hearts received three 2-minute cardioplegic infusions (1 mmol/L calcium) at 4 degrees, 20 degrees, and 37 degrees C in random order, each followed by 10 minutes of beating at 37 degrees C. Finally, warm induction of arrest by a 1-minute cardioplegic infusion at 37 degrees C was followed by a 1-minute infusion at 4 degrees C. Indo-1 was used to measure the intracellular Ca2+ concentration in 6 of these hearts. Additional hearts received hypoxic, glucose-free cardioplegia at 4 degrees or 37 degrees C., Results: After 1 minute of cardioplegia at 4 degrees, 20 degrees, and 37 degrees C, left ventricular developed pressure rose rapidly to 54% +/- 3%, 43% +/- 3%, and 18% +/- 1% of its prearrest value, whereas the intracellular Ca2+ concentration reached 166% +/- 23%, 94% +/- 4%, and 37% +/- 10% of its prearrest transient. Coronary flow was 5.7 +/- 0.2, 8.7 +/- 0.3, and 12.6 +/- 0.6 mL/min, respectively. Warm cardioplegia induction at 37 degrees C reduced left ventricular developed pressure and [Ca2+]i during subsequent 4 degrees C cardioplegia by 16% (p = 0.001) and 34% (p = 0.03), respectively. Adenosine triphosphate and phosphocreatine contents were lower after 4 degrees C than after 37 degrees C hypoxic, glucose-free cardioplegia., Conclusions: Rapid cooling during cardioplegia increases left ventricular pressure, [Ca2+]i and coronary resistance, and is energy consuming. The absence of rapid cooling contracture may be a benefit of warm heart operations and warm induction of cardioplegic arrest.