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The debate about the optimal mitral valve prosthesis continues. We aimed to compare the early and late outcomes, including stroke, bleeding, survival, and reoperation after isolated mitral valve replacement (MVR) using tissue versus mechanical valves.This retrospective cohort study included 291 patients who had isolated MVR from 2005 to 2015. Patients were grouped into the tissue valve group (n = 140) and the mechanical valve group (n = 151).There were no differences in duration of mechanical ventilation, hospital stay, and hospital mortality between groups. Fifteen patients required cardiac rehospitalization, nine in the tissue valve group, and six in the mechanical valve group (p = .44). Stroke occurred in nine patients, five with tissue valves, and four with mechanical valves (p = .66). Bleeding occurred in 22 patients, seven patients with tissue valves, and 15 patients with mechanical valves (p = .09). Freedom from reoperation was 95%, 93%, 84%, 67% at 3, 5, 7, and 10 years for tissue valve and 97%, 96%, 96%, and 93% for mechanical valves, respectively (p˂ .001). The median follow-up was 84 months (Q1: Q3: 38-139). Survival at 3, 5, 7, and 10 years was 94%, 91%, 89%, 86% in tissue valves and 96%, 93%, 91%, 91% in mechanical valves, respectively (p = .49).Tissue valve degeneration is still an issue even in the new generations of mitral tissue valves. The significant risk of reoperation in patients with mitral tissue valves should be considered when using those valves in younger patients. Mechanical valves remain a valid option for all age groups.

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP ( n = 43) and ECMO with IABP ( n = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction ( p = 0.002). There was no difference in stroke ( p = 0.97), limb ischemic ( p = 0.32), and duration of ICU stay ( p = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p = 0.01), active endocarditis (OR: 0.06; p = 0.02), older age (OR: 0.95; p = 0.02), and aortic valve replacement (OR: 0.26; p = 0.04). There was no difference in survival between groups ( p = 0.80). Our study did not support the routine use of IABP during ECMO support.

The effect of different degrees of right ventricular (RV) dysfunction on long-term outcomes after tricuspid valve repair is the subject of ongoing research. We sought to evaluate the effect of preoperative RV dysfunction on mortality and recurrence of tricuspid regurgitation (TR) after tricuspid valve repair for secondary TR concomitant with left-side valve surgery. This is a retrospective study, including 548 patients who underwent repair of secondary TR (2009–2017) at a single institution. Patients were grouped according to preoperative right ventricular (RV) systolic function into three groups; normal RV function (group 1, n = 451), mild RV dysfunction (group 2, n = 60) and moderate/severe RV dysfunction (group 3, n = 37). Study endpoints were mortality and recurrence of TR. Group 3 was associated with the highest hospital mortality (10.2%, p = .06). Predictors of moderate or higher grade TR were NYHA class (HR 2.1, p = 0.03); preoperative TR grade (HR 1.9, p

Background Paediatric del Nido cardioplegia (DNC) has been tested in selected populations of low-risk adult patients. This study examined its use in an unselected medium-to-high-risk adult population and compared the results with a propensity-matched population that received intermittent warm blood cardioplegia (IWBC). Methods Data from the last 1,000 consecutive adult patients who underwent a variety of surgical procedures under cardioplegic arrest with the use of IWBC or DNC between 2016 and 2018 were propensity score matched on preoperative clinical and demographic variables. Two (2) main populations were 102 patients who received DNC and another set of matched 102 patients from a total of 1,000 patients who received IWBC, along with a subgroup with an ejection fraction (EF) ≤40% (EFDNC vs EFIWBC). Postoperative outcomes were mortality, peak troponin T, postoperative EF%, and aortic cross-clamp time. Results There were no preoperative differences amongst the groups in the main cohort (Euroscore II: DNC 4.1±8, IWBC 4.0±7; EF%: DNC 47±10, IWBC 47±11) and in the subgroup (EF%: EFDNC 32±6%, EFIWBC 32±6%; p=0.45). There were also no differences in three of the outcomes. A significant postoperative improvement was noticed in the EF% in the DNC (32±6% 95% CI 29-34 to 39±12 95% CI 34-44; p=0.001) in the EFDNC group. Conclusions This initial experience of del Nido cardioplegia proved to be effective in a variety of challenging pathologies in adult populations.

We present a 57-year-old man with recent Streptococcus viridans endocarditis on mitral and aortic valves who had a mycotic aneurysm of the left anterior descending (LAD) coronary artery and associated superior mesenteric and cerebral artery aneurysms. The patient had preoperative renal failure and the infection was controlled with ceftriaxone. Mitral and aortic valve replacement were performed using tissue valves and the LAD aortic aneurysm was ligated and the patient had saphenous venous graft to the LAD. The postoperative course was complicated by pleural effusion and the patient had antibiotic therapy for 6 weeks postoperatively.

Background Transcatheter Mitral Valve-in-Valve Implantation (TMViVI) has recently emerged as a novel therapy for degenerated mitral valve bioprosthesis. Re-operative mitral valve surgery is associated with a substantial risk of mortality and morbidity. The objective of this study was to describe the outcomes of transcatheter mitral valve-in-valve implantations in our cardiac center. Methods Twenty-two patients underwent the valve-in-valve procedure because of bioprosthesis degeneration from March 2017 to October 2018. Clinical, echocardiographic, procedural details and survival at follow up were assessed. Results Eight patients refused re-operative cardiac surgery while others were deemed a high risk for conventional re-operative sternotomy. All patients had TMViVI performed via a trans-septal approach, and the prosthesis was implanted successfully with immediate hemodynamic improvement in 20 patients. One patient had tamponade (4.55%), two had permanent pacemaker insertion (9.09%), two patients had a renal impairment (9.09%), and three patients had vascular complications (13.64%). There was one aborted procedure for the failure to cross the tissue valve with a transcatheter valve, and one patient was converted to an emergency mitral valve surgery. All patients were discharged in NYHA class I/II and NYHA class was markedly improved at one-year follow-up (p = 0.002). Conclusions Trans-septal mitral valve-in-valve implantation can be performed safely for degenerative mitral valve bioprosthesis and with favorable early clinical and hemodynamic outcomes.

Background Tricuspid valve regurgitation may affect the outcomes after heart transplantation. There is a paucity of data reporting the outcomes of heart transplants in our region. The objectives of this study were to report the occurrence of tricuspid regurgitation after heart transplantation, its course, and its effect on survival. Methods From 2009 to 2019, 30 patients had heart transplantation at our cardiac center. Their age was 36.73 ± 13.5 years, and 25 (83.33%) were males. Indications for transplantation were dilated cardiomyopathy (n = 21; 72.41%), ischemic cardiomyopathy (n = 8; 26.67%) and hypertrophic cardiomyopathy (n = 1; 3.45%). Cardiopulmonary bypass time was 157.24 ± 34.6 min, and ischemic time was 138 ± 73.56 min. All patients had orthotopic heart transplantation with a bi-caval technique. Results Eleven patients had severe tricuspid regurgitation postoperatively (37%). The degree of tricuspid regurgitation decreased significantly after 6 months (p = 0.011) and remained stationary during the follow-up. Pre-transplant dilated cardiomyopathy was significantly associated with severe tricuspid regurgitation post-transplant (p = 0.017). The mean follow-up was 39.43 ± 50.57 months. Survival at 10 years was 90% in patients with less than moderate tricuspid regurgitation postoperatively compared to 43% for patients with moderate and severe tricuspid regurgitation (log-rank p = 0.0498). Conclusion Tricuspid regurgitation is a common problem after heart transplantation. Despite the improvement of the degree of tricuspid regurgitation after 6 months, survival was negatively affected by postoperative moderate or severe tricuspid regurgitation. Patients with dilated cardiomyopathy may benefit from concomitant tricuspid valve repair at the time of heart transplantation. Further larger studies are warranted.

The influence of the etiology of mitral valve (MV) lesion on outcomes of concomitant repair for functional tricuspid regurgitation (TR) is not well studied. Our objectives were to compare long-term survival and TR recurrence after tricuspid valve (TV) repair concomitant with surgery for rheumatic versus degenerative MV disease.We included 480 patients who had concomitant MV and TV surgery from 2009 to 2019. We grouped the patients into Group 1 (n = 345; rheumatic MV) and Group 2 (n = 135; degenerative MV). Propensity score matching identified 104 matched pairs.There was no significant difference in survival between groups before (p = .46) or after matching (p = .09). There was no difference in the recurrence of moderate TR (subdistributional hazard ratio [SHR]: 1.22 [0.77-1.95], p = .40). Recurrent TR was significantly associated with the preoperative TR grade (SHR: 1.8 [1.5-2.16], p .001); body mass index (SHR: 1.05 [1.03-1.08], p .001), and the use of flexible versus rigid TV prosthesis (SHR: 0.64 [0.41-0.99], p = .042). Recurrence of TR was higher with MV replacement compared with repair (SHR: 1.69 [1.03-2.78], p = .038). The change in the degree of TR did not differ between groups before matching (OR: 0.77 [0.56-1.04], p = .09) or after matching (OR: 0.98 [0.67-1.44]; p = .93).Outcomes of concomitant TR repair were comparable in rheumatic and degenerative mitral pathology. Type of the TV prosthesis and TR grade affected TR recurrence. MV repair could be associated with a lower recurrence of TR compared with replacement.

Introduction: There are scarce data comparing different mechanical valves in the aortic position. The objective of this study was to compare the early hemodynamic changes after aortic valve replacement between ATS, Bicarbon, and On-X mechanical valves. Methods: We included 99 patients who underwent aortic valve replacement with mechanical valves between 2017 and 2019. Three types of mechanical valves were used, On-X valve (n=45), ATS AP360 (n=32), and Bicarbon (n=22). The mean prosthetic valve gradient was measured postoperatively and after six months. Results: Preoperative data were comparable between groups, and there were no differences in preoperative echocardiographic data. Pre-discharge echocardiography showed no difference between groups in the ejection fraction (P=0.748), end-systolic (P=0.764) and end-diastolic (P=0.723) diameters, left ventricular mass index (P=0.348), aortic prosthetic mean pressure gradient (P=0.454), and indexed aortic prosthetic orifice area (P=0.576). There was no difference in the postoperative aortic prosthetic mean pressure gradient between groups when stratified by valve size. The changes in the aortic prosthetic mean pressure gradient of the intraoperative period, at pre-discharge, and at six months were comparable between the three prostheses (P=0.08). Multivariable regression analysis revealed that female gender (beta coefficient -0.242, P=0.027), body surface area (beta coefficient 0.334, P

Background The number of MtraClip procedures is increasing, and consequently, the number of patients with residual or recurrent mitral regurgitation (MR). We aimed to characterize patients who had residual versus recurrent MR after MitraClip and report the outcomes of different treatment strategies. Methods From 2012 to 2020, 167 patients had MitraClip. Out of them, 16 patients (9.5%) had residual mitral regurgitation (MR), and 27 patients (16.2%) had recurrent MR. Results The median age in patients with residual MR was 67.5 (59-73) years versus 69 (61-78) years in patients with recurrent MR (p = .87). The etiology of mitral valve disease was functional in 13 patients (81.3%) and 22 patients (84.6%) in residual versus recurrent MR patients (p > .99). Cardiac resynchronization therapy-defibrillator implantation was higher in patients with residual MR (p = .02). Survival was 93.7% at 1 year, 76.4% at 3 years versus 92.5% at 1 year, and 84.5% at 3 years in residual versus recurrent MR (p = .69). Two patients in the residual MR group had re-clip, and three had surgery, and in the recurrent MR group, one patient had re-clip, and two patients had surgery (p = .23). Patients who had re-clip were older (p = .09). Surgery was associated with 100% survival at 5 years, 63% after medical therapy and the worst survival was reported in re-clip patients (p = .007). Conclusion The outcomes of patients with residual versus recurrent mitral regurgitation after MitraClip were comparable. Survival could be improved with surgery compared with medical therapy and re-clip.

Objectives Left ventricular diastolic dysfunction (LVDD) in patients undergoing transcatheter aortic valve replacement (TAVR) is associated with poor outcomes; however, the effect of its severity is controversial. We sought to assess the impact of diastolic dysfunction on hospital outcomes and survival after TAVR and identify prognostic factors. Methods We included patients who underwent TAVR for severe aortic stenosis with preexisting LVDD from 2009 to 2018 (n = 325). Patients with prior mitral valve surgery (n = 4), atrial fibrillation (n = 39), missing or poor baseline diastolic dysfunction assessment (n = 36) were excluded. The primary endpoint was all-cause mortality. 246 patients were included in the study. Results The median age was 80 years (25th and 75th percentiles:75-86.7), 154 (62.6%) were males and the median EuroSCORE II was 4.3 (2.2-8). Patients with severe LVDD had significantly higher EuroSCORE, and lower ejection fraction (p < 0.001). There was no difference in post-TAVR new atrial fibrillation (p = 0.912), pacemaker insertion (p = 0.528), stroke (p = 0.76), or hospital mortality (p = 0.95). Patients with severe LVDD had longer hospital stay (p = 0.036). The grade of LVDD did not affect survival (log-rank = 0.145) nor major adverse cardiovascular events (log-rank = 0.97). Predictors of mortality were; low BMI (HR: 0.95 (0.91-0.99); p = 0.019), low sodium (0.93 (0.82-2.5); p = 0.021), previous PCI (HR: 1.6 (1.022-2.66); p = 0.04), E-peak (HR: 1.01 (1.002-1.019); p = 0.014) and implantation of more than one device (HR: 3.55 (1.22-10.31); p = 0.02). Conclusion Transcatheter aortic valve replacement is feasible in patients with diastolic dysfunction, and the degree of diastolic dysfunction did not negatively affect the outcome. Long-term outcomes in those patients were affected by the preoperative clinical state and procedure-related factors.

BACKGROUND AND AIM OF STUDY Several studies reported the safety and potential benefits of single-dose Del Nido cardioplegia (DNC) in selected adult cardiac surgery (ACS) procedures. However, studies are scarce on routine use of DNC in more complex procedures and patients with a high risk profile. We sought to compare DNC with cold blood cardioplegia (BC) in all types of ACS including complex procedures. METHODS Data for 305 consecutive unselected patients who underwent ACS procedures (July/2017 to November/2019) were included. DNC was routinely used whenever is available (n = 231) and if not available, cold BC is used (n = 74). All categories of ACS procedures (primary or redo) were included. Repeated measures analysis was performed to compare baseline, peak, and trough Troponins levels in both groups. Linear regression analysis was used to identify independent predictors of peak Troponins level. RESULTS The two groups were comparable in baseline characteristics including euro score (ES II), risk profile, and surgical complexity. DNC was associated with lower cardiopulmonary bypass (CPB) and cross-clamp times, cardioplegia volume, and number of cardioplegia doses (p

BACKGROUND The benefit of mitral valve repair (MVr) over replacement in patients with severe ischemic mitral regurgitation (IMR) is still controversial. We report our early postoperative outcomes of repair versus replacement. METHODS Data were collected for patients undergoing first-time mitral valve surgery for severe IMR between 1990 and 2009 (n = 393). Patients who underwent combined procedures for papillary muscle rupture, post-infarction ventricular septal defect, endocarditis, or any previous cardiac surgery were excluded. Preoperative demographics, operative variables, and hospital outcomes were analyzed, and multivariable regression analysis was employed to identify independent predictors of hospital mortality. RESULTS Valve repair was performed in 42% (n = 164) of patients and replacement in 58% (n = 229). Patients who underwent replacement were older and had a higher prevalence of unstable angina, New York Heart Association Class IV symptoms, preoperative cardiogenic shock, preoperative myocardial infarction, peripheral vascular disease, renal failure, and urgent or emergency surgery (all p

The effect of different degrees of right ventricular (RV) dysfunction on long-term outcomes after tricuspid valve repair is the subject of ongoing research. We sought to evaluate the effect of preoperative RV dysfunction on mortality and recurrence of tricuspid regurgitation (TR) after tricuspid valve repair for secondary TR concomitant with left-side valve surgery.This is a retrospective study, including 548 patients who underwent repair of secondary TR (2009-2017) at a single institution. Patients were grouped according to preoperative right ventricular (RV) systolic function into three groups; normal RV function (group 1, n = 451), mild RV dysfunction (group 2, n = 60) and moderate/severe RV dysfunction (group 3, n = 37). Study endpoints were mortality and recurrence of TR.Group 3 was associated with the highest hospital mortality (10.2%, p = .06). Predictors of moderate or higher grade TR were NYHA class (HR 2.1, p = 0.03); preoperative TR grade (HR 1.9, p 0.01), mild RV dysfunction (HR 2.4, p 0.01), isolated RV dilatation (HR 2.0, p 0.01), and flexible TV repair prostheses (HR 2.4, p = 0.01). Predictors of mortality were renal impairment (HR 3.0, p 0.01), ejection fraction (HR 0.97, p = 0.02), pulmonary artery systolic pressure (HR 1.02, p = 0.02), preoperative TR grade (HR 1.7, p 0.01), and moderate/severe RV dysfunction (HR 3.1, p = 0.01).Compared to normal and mild degree of RV dysfunction, moderate and severe RV dysfunction were independent predictors of poor long-term survival. Isolated RV dilatation increased the recurrence of TR. RV dysfunction and dilatation could be indications of tricuspid valve repair.

Left ventricular diastolic dysfunction (LVDD) in patients undergoing transcatheter aortic valve replacement (TAVR) may be associated with poor outcomes. We sought to assess the effect of LVDD on hospital outcomes and survival after TAVR in patients with severe aortic stenosis and identify the

Background: Pain management remains an integral part of patient care after cardiac surgery, and it required proper pain assessment. The aim of the study was to assess pain perception using validated Arabic version of the short-form McGill Pain Questionnaire (SF-MPQ) and to identify analgesics prescribing patterns post cardiac surgery. Methods: This is a prospective study conducted in an adult cardiac critical care unit of a tertiary cardiac center from September 2018 to March 2019. The study enrolled 74 patients who underwent cardiac surgical procedures through a median sternotomy. Results: The mean age of our patients was 57 ± 11 years and 47 (63.5%) were males. Patients described post-cardiac surgery pain as heavy (n = 37; 50%) and tiring-exhausting (n = 49; 66%), mainly at the site of incision (n = 20; 27%). Pain intensity at day 1 according to pain rating index (PRI) and numerical rating scale (NRS) was 7 (25th, 75th percentiles: 2.8–15) and 6 (3–8), respectively. There was a significant change in pain intensity score between 2 days of assessment (PRI: 7 [2.8–15] vs 5 [2–11] P = 0.010; NRS: 6 (3–8) vs 5 (2–8), P = 0.021]). The most common analgesics prescribed were paracetamol (39%) and a combination of tramadol and paracetamol (33.8%). Conclusion: Pain decreased the second day after cardiac surgery compared to day 1. Paracetamol was the most prescribed analgesic; however, there was an underutilization which might be affected by insufficient pain reporting. Future improvement could focus on multimodal pain management and proper communication of pain experience.

Minimally invasive mitral valve surgery (MIMVS) has emerged as an alternative approach to conventional sternotomy to perform mitral valve repair and replacement with equivalent results. This strategy was developed to decrease surgical trauma by minimizing the size of incisions and permits excellent exposure of the mitral valve thereby avoiding conventional full sternotomy. The purpose of this review is to provide a critical, objective, balanced, and evidence-based analysis of the literature to understand advantages, potential scope, and the utility of these minimally invasive approaches to the mitral valve in modern cardiac care.

ObjectiveTo determine the impact of the degree of hypothermia on surgical outcomes in patients undergoing repair of acute type A aortic dissection.MethodsBetween 1990 and 2010, 211 consecutive patients underwent surgical repair of type A aortic syndrome. Patients with acute type A dissection (n = 128) were included. Circulatory arrest with profound hypothermia (PH

Objective Primary coronary artery bypass grafting (CABG) is performed routinely in elderly patients with good results. However, the risk profile and outcomes of reoperative CABG in elderly patients are not well defined. Our purpose was to study the risk profile and hospital outcomes of isolated reoperative CABG in elderly patients (75 years and older) compared to isolated primary CABG in the same age group. Methods Between January 1990 and December 2010, 3483 elderly patients (age ≥ 75 years) underwent isolated CABG at our institution. Of these, 129 (3.7%) underwent reoperative CABG. Data were prospectively collected in a computerized database. Independent predictors of hospital mortality were determined by multivariable logistic regression. Results Hospital mortality was 3.2% and 8.5% (p

Microplegia delivers blood and additives for cardioplegia with minimal crystalloid. We retrospectively compared microplegia with standard 8:1 blood cardioplegia with a propensity-matched analysis in patients undergoing isolated coronary artery bypass graft (CABG) surgery.Prospectively collected data for 2,630 consecutive patients who underwent isolated CABG surgery (2004 to 2006) with the exclusive use of microplegia was compared with an equivalent 3-year cohort (1998 to 2000) of 5,058 consecutive isolated CABG patients with the exclusive use of 8:1 diluted blood cardioplegia. Propensity score matching identified 1,980 matched pairs (in each group) for analysis.In the matched groups, the hospital mortality was identical (1.2%). The prevalence of low cardiac output syndrome was significantly (p0.001) lower in the later period when microplegia was employed (2.7%) compared with the standard cardioplegia group (5.0%). Although these results may also reflect improvements in care with time, a multivariable logistic regression analysis of the entire cohort (not matched) also demonstrated a twofold independent reduction in low cardiac output syndrome in microplegia patients (odds ratio, 1.9; 95% confidence interval 1.4 to 2.5).Compared with 8:1 blood cardioplegia, microplegia during isolated CABG surgery was associated with a lower incidence of postoperative low cardiac output syndrome. Microplegia may reduce postoperative cardiac edema, increase buffering, and permit more rapid recovery of ventricular function. Randomized trials are required to determine whether the relationship between microplegia and reduced low output syndrome is causal or is merely an association.

Introduction: The use of mechanical circulatory support (MCS) in nontransplant eligible candidates remains controversial. Our decision to offer MCS for nontransplant candidates has led to their reevaluation after a period of left ventricular assist device (LVAD) support. Methods: From 2001 to September 2009, we had 37 patients who received an implantable LVAD, 22 (59%) were not deemed to be transplant eligible at the time of LVAD insertion (bridge to candidacy, BTC group). Results: Fifteen (41%) patients were considered transplant eligible (bridge to transplant, BTT group) at the time of device insertion and received a HeartMate XVE (n = 7), HeartMate 2 (n = 7), or a Novacor LVAS (n = 1). In the BTC group, patients received the HeartMate XVE device (n = 11), HeartMate 2 (n = 5), or the Novacor LVAS (n = 6). The primary criterion for transplant ineligibility was refractory pulmonary hypertension (PH) in 18 patients, 3 patients did not meet our body mass index criteria (>35 kg/m2), and 2 patients were dialysis-dependent. Six (27%) BTC patients died on support. Overall, 16/22 patients (73%) were subsequently listed for transplantation, with one listed for combined heart–lung due to refractory PH. Twelve patients (75%) underwent successful heart transplantation. Three patients died during their transplant. Overall posttransplant survival at one year shows lower survival in the BTC group compared to the BTT group (67% vs. 100%, p = 0.05). At two years and three years the survival was lower, but not statistically different (BTC vs. BTT: 67% vs. 90% and 64% vs. 87%, respectively, p = NS). Conclusions: MCS can successfully convert a large proportion of transplant-ineligible patients into acceptable candidates. (J Card Surg 2011;26:542-547)

Robotic-assisted mitral valve repair represents the least invasive surgical approach currently available for anatomical mitral valve repair in patients with myxomatous mitral valve disease. Standard mitral valve repair techniques utilized during conventional sternotomy/right thoracotomy are exactly replicated with the robotic instrumentation through 1-2 cm port-like incisions with superior 3D visualization. This is performed on cardiopulmonary bypass by peripheral cannulation of the femoral vessels/right internal jugular vein. The ascending aorta is occluded with a transthoracic aortic cross-clamp. Antegrade cardioplegia is delivered centrally into the aortic root through a cardioplegia vent catheter. By replicating conventional mitral valve repair done via an open sternotomy approach, the quality of mitral valve repair is ensured while providing the patients with advantages of less invasive surgery including shorter hospital stay, rapid recovery and return to normal activities, less blood transfusion, superior cosmesis and complete elimination of sternotomy-related morbidities such as deep sternal wound infection and sternal dehiscence. We reviewed the first consecutive 200 patients undergoing robotic mitral valve repair at Mayo Clinic Rochester between 24 January 2008 and 28 January 2011. Successful mitral valve repair was completed in all patients. There were no early (30-day) deaths. One patient suffered a stroke (0.5%). One patient required reoperation for bleeding (0.5%). Two patients (1%) required reoperation for recurrent mitral regurgitation. Twelve patients (6%) required transfusion of allogeneic blood products. We have noted a significant reduction in operative times and resource utilization over time.

Objectives To identify novel predictors for coronary artery bypass grafting failure, we probed for associations with known clinical and biochemical risk factors for atherosclerosis. We also used microarray analysis to identify novel single nucleotide polymorphisms to better understand the genetics and pathogenesis of graft occlusion. Methods The present study was a nested case-control substudy of the Radial Artery Patency Study 5-year follow-up data. From 1996 to 2001, 87 patients underwent coronary artery bypass grafting. Of these, 26 patients (29.9%) had an occluded study graft (saphenous vein or radial artery) at 8.0 ± 1.1 years. The clinical parameters, late angiography, blood biomarker levels, and surgical outcomes data were included in a multivariate analysis to determine the independent predictors of graft failure. Results The risk factors of graft failure were fibrinogen (odds ratio [OR], 3.94; 95% confidence interval [CI], 1.33-11.63; P = .01), creatinine (OR, 1.06; 95% CI, 1.02-1.10; P = .006), and diabetes mellitus (OR, 5.15; 95% CI, 1.08-24.59; P = .04). High-density lipoprotein (OR, 0.74; 95% CI, 0.53-1.02; P = .06) was weakly protective; however, low-density lipoprotein and total cholesterol were not predictors. We then identified the association of several human single nucleotide polymorphisms with graft failure, including mutations in glutathione-S-transferase α3 . Human coronary arteries and bypass grafts demonstrated increased protein expression of glutathione-S-transferase α3, a known cardioprotective factor, in the atherosclerotic regions and surrounding adventitial tissues. Conclusions We identified diabetes as a potential clinical predictor and plasma fibrinogen, creatinine, and high-density lipoprotein as potential novel biomarkers. These might help risk stratify patients for the development of graft failure. We also demonstrated a novel association between glutathione-S-transferase α3 and graft failure.

The proportion of elderly patients undergoing isolated coronary artery bypass grafting (CABG) surgery has steadily increased. We have evaluated temporal trends in hospital outcomes of patients who were 75 years and older undergoing CABG (1990-2010) at our institution.Data were collected prospectively for 3483 consecutive patients who were 75 years and older (median 78 years; range 75-94) undergoing isolated CABG at our institution over three time cohorts: 1990-96 (n = 817), 1997-2003 (n = 1534) and 2004-10 (n = 1132).Overall mortality declined from 6.0% (49/817) in the earliest era (1990-96) to 1.9% (22/1132) in the most recent era (2003-10; P0.001). Mortality in low-risk patients (elective, primary surgery with the ejection fraction40%) was 5.9% (13/220), 0.8% (4/514) and 0% (0/411) in the first, second and third eras, respectively (P0.001). Despite the overall increase in comorbidities in our elderly patients, the prevalences of certain risk factors such as poor LV function, urgency of surgery and reoperation have all declined with time. The independent risk factors for mortality in our population were congestive heart failure, left main disease, earlier year of operation, reoperation, preoperative myocardial infarction, cardiopulmonary bypass time, emergent/urgent surgery and peripheral vascular disease. Of these, earlier year of operation (OR: 3.0; 95% CI: 1.8-5.2) was the most significant predictor. Also, age80 did not predict mortality.The principle finding from this analysis is a contemporary low operative mortality for CABG in an elderly patient cohort. Risk of death is particularly low in a low-risk subset of elderly patients with reasonable LV function undergoing elective, primary CABG.

Atrial fibrillation (AF) is the most common arrhythmia in adults and a major burden of morbidity and mortality in cardiovascular patients (1). The major sequelae are cardiovascular and include heart failure and thromboembolic events, primarily stroke. The prevalence of AF is 0.4-1% in the overall population which rises with age to approximately 15% in those patients 70 years and older (2). The incidence of AF is rising due in part to the increase in the aging population, increase in those living with structural cardiovascular pathology and more frequent diagnosis from the use of ambulatory monitoring devices. Overall, AF affects more than 2.5 million adult in the US and 200,000 to 250,000 in Canada (Heart and Stroke Foundation of Canada statistics; http://www.heartandstroke.com). Overall, this represents a considerable burden of illness in vulnerable populations such as the elderly and those with congestive heart failure. The Framingham Study found that development of chronic AF was associated with a twofold increase in mortality from cardiovascular disease (2). Furthermore, AF was an independent risk factor for mortality in this population (3). The risk of stroke with persistent AF is 8% per year and 2% per year with warfarin. This is balanced with a bleeding risk of 2% per year while on warfarin at an INR of 2-3 (4). Of 5070 patients in the Framingham Study followed for 34 years, a two-fold increase in stroke events were found with AF with higher rates in those with heart failure (5). The attributable risk of stroke increases with age from 1.5% for the youngest cohort (50-59 years) to 23.5% for the oldest cohort (80-89 years). AF is defined based on the clinical presentation, relevant patient characteristics and any associated cardiac pathology. There is considerable variation in the descriptors for types of atrial fibrillation. These include acute, chronic, long-standing, sustained, recurrent, and so forth. The Society of Thoracic Surgeons (STS) has published reporting guidelines to facilitate consistency in reporting which include classification of AF as paroxysmal, persistent and permanent; duration of arrhythmia and patient burden (percentage of overall time in AF) as well as previous interventions and relevant patient characteristics such as association with cardiac pathology (6). The European Society of Cardiology differs in that for AF lasting greater than 1 year, patients undergoing a rhythm control strategy have longstanding persistent AF whereas patients who have accepted the arrhythmia and are not therefore treated with rhythm control therapy have permanent AF. Table 1 provides the descriptors and definitions of AF utilized in this chapter.

Postoperative low cardiac output syndrome (LCOS) is associated with high morbidity and mortality after coronary artery bypass grafting (CABG). We sought to examine trends in predictors of LCOS after isolated CABG.A total of 25,176 consecutive patients who underwent isolated CABG between 1990 and 2009 were included. To examine trends over time, we divided patients into four equivalent eras (1990 to -1994, n = 6,489; 1995 to 1999, n = 8,175; 2000 to 2004, n = 6,741; 2005 to 2009, n = 3,797). We used multivariable analysis to identify predictors of LCOS.The prevalence of LCOS declined from 9.1% (1990 to 1994) to 2.4% (2005 to 2009, p0.001). The following were the major independent predictors of LCOS for the entire cohort (odds ratios in parentheses): reoperative CABG (4.1); earlier year of operation (4.1, 2.6, 1.7 for the first, second, and third eras, respectively); left ventricular ejection fraction (LVEF) less than 0.20 (3.5), emergency surgery (2.7), cardiogenic shock (2.3), female gender (2), and LVEF 0.20 to 0.39 (2). Unlike other risk factors, the impact of LVEF less than 0.20 on development of postoperative LCOS increased substantially in the latest era (odds ratio, 7.8) compared with (odds ratios, 3.1, 4.3, and 3.2) the first, second, and third eras, respectively.The impact of LVEF less than 0.20 on development of postoperative LCOS has increased markedly in the latest era of our study. Prudent preoperative evaluation in patients with severe left ventricular dysfunction is critical. Further innovative research in myocardial protection and circulatory support is warranted in patients with severe left ventricular dysfunction.

An 80-year-old man with symptomatic severe aortic valve stenosis was referred for transcatheter aortic valve replacement (TAVR) after balloon aortic valvuloplasty (BAV). The TAVR procedure was aborted because of identification of a mobile mass attached to the leading edge of the right cusp of the aortic valve on a transesophageal echocardiography. Surgical aortic valve replacement (SAVR) was performed and this mass was found to be an aortic cusp fenestration rupture that was caused by the BAV. doi: 10.1111/jocs.12451 (J Card Surg 2015;30:251–252)

ObjectivesThe number of patients referred for coronary artery bypass grafting (CABG) has fallen, whereas their risk profile appears to be increasing. We evaluated changes in the predictors of hospital mortality among patients undergoing CABG during a span of 18 years.MethodsData were collected prospectively for all patients undergoing isolated CABG (n = 23,445) from 1991 to 2008. To examine the effect of time on patients’ risk profiles and outcomes, we divided patients into 3 time cohorts (1991-1996, n = 8280; 1997-2002, n = 9801; 2003-2008, n = 5364). We used multivariable logistic regression model to identify predictors of mortality in the entire cohort and in each time cohort.ResultsHospital mortality declined from 2.4% (1991-1996) to 1.2% (2003-2008; P