Search

Background: The LATERAL trial validated the safety and efficacy of the thoracotomy approach for implantation of the HeartWare HVAD System, leading to Food and Drug Administration approval. We sought to analyze 24-month adverse event (AE) rates, including a temporal analysis of the risk profile, associated with the thoracotomy approach for the HVAD system., Methods: AEs from the LATERAL trial were evaluated over 2 years postimplant. Data was obtained from the Interagency Registry for Mechanically Assisted Circulatory Support database for 144 enrolled United States and Canadian patients. Temporal AE profiles were expressed as events per patient year., Results: During 162.5 patient years of support, there were 25 driveline infections (0.15 events per patient year), 50 gastrointestinal bleeds (0.31 events per patient year), and 21 strokes (0.13 events per patient year). Longitudinal AE analysis at follow-up intervals of <30 and 30 to 180 days, and 6 to 12 and 12 to 24 months revealed the highest AE rate at <30 days, with a decrease in total AEs within the first 6 months. After 6 months, most AE rates either stabilized or decreased through 2 years, including a 95% overall freedom from disabling stroke., Conclusions: Two-year follow-up of the LATERAL trial revealed a favorable morbidity profile in patients supported with the HVAD system, as AE rates were more likely to occur in the first 30 days postimplant, and overall AE rates were significantly reduced after 6 months. Importantly, 2-year freedom from disabling stroke was 95%. These data further support the improving AE profile of patients on long-term HVAD support. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02268942.

Background: The incidence of right ventricular dysfunction requiring right ventricular assist device after left ventricular assist device placement has been reported between 10% to 30%. The mortality rate is higher compared with patients who require left ventricular assist device only; the most effective and safest biventricular assist device remains unknown. We aimed to determine the survival outcomes and frequency of adverse events in patients with two durable, intracorporeal, continuous flow centrifugal pumps for support., Methods: Between November 2012 and June 2015, 38 patients were identified from INTERMACS received durable, intracorporeal continuous flow centrifugal pumps for biventricular support. Pediatric patients were excluded. Mean age was 47 years, and 74% of patients were male. The common primary diagnoses in this cohort were dilated myopathy, idiopathic (37%) and ischemic (16%)., Results: Nineteen participating centers implanted devices in 38 patients; 11 patients died with device in place, 9 patients received a heart transplant, and 18 were alive on support with the right ventricular assist device in place. Survival outcomes were 68% at 6 months and 62% at 12 months. The left ventricular assist device was placed in the left ventricle apex in 91% of cases, and in 9%, the location was not specified. The right ventricular assist device was placed in the right ventricle in 50%, right atrium in 37%, and not specified in 13%. The adverse events included infection 50%, bleeding 44%, respiratory failure 31.6%, and malfunction 26.3%; neurologic dysfunction 26.3%; renal dysfunction 18.4%; and arrhythmia 18.4%., Conclusions: The use of durable, intracorporeal, continuous flow centrifugal pumps for management of advanced biventricular heart failure is associated with high morbidity and mortality. Further investigation of this device configuration is warranted., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The HeartWare Ventricular Assist System (HVAD) provides significant improvements in survival and quality of life, and here, we seek to evaluate temporal differences in the adverse event (AE) rates. Patients (n = 382) in the ADVANCE bridge-to-transplant and continued access protocol trial were assessed for bleeding, cardiac arrhythmia, infection, ischemic and hemorrhagic stroke, and right heart failure during predetermined time periods (≤30, >30-180, >180-365, >365-730, >730-1,095 days) after HVAD implant. The Kaplan-Meier survival at 30 days, 6 months, 1, 2, and 3 years was 98%, 90%, 84%, 71%, and 63%, respectively. There were significantly fewer total AEs in days >30-180 (events per patient year [EPPY] = 5.34) compared with the first 30 days post HVAD implantation (EPPY = 30.36; p < 0.0001). The total AE rate in days >180-365 (EPPY = 4.09) was also significantly lower than the event rate in days >30-180 (EPPY = 5.34; p < 0.0001). Incidence of cardiac arrhythmias, infections, strokes, and right heart failure were highest immediately post implant and lower rates occurred after 6 months. After 1 year, all AEs exhibited stable rates that were comparable up to 3 years of support (all p > 0.05). This changing risk over time has clinically meaningful implications toward improving patient management.

Objectives: We examined whether gender differences exist regarding stress, symptom distress, coping, adherence, and social support 5 years after heart transplantation., Background: Differences exist in health-related quality of life outcomes by gender after heart transplantation; women report poorer outcomes., Methods: Patients (n = 210, female = 42), were from a prospective, multi-site, study of health-related quality of life long-term after heart transplantation. Patients completed self-report instruments 5 years after heart transplantation (mean = 4.98 ± 0.17 years after transplant). Statistical analyses included two-sample t-tests, Chi-square or Fisher's exact test, and multivariable modeling., Results: Women did not report more overall stress or symptom distress, but reported more difficulty adhering to the transplant regimen, yet more actual adherence than men. Women reported using more negative coping styles, but reported more satisfaction with social support., Conclusions: Gender differences exist regarding appraisal of stress, coping styles, and coping resources long-term after heart transplantation. These differences may guide tailoring therapy regarding stress, poor coping, and lack of resources., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Generic and heart failure (HF)-specific health-related quality of life (HRQOL) instruments do not address unique burdens of mechanical circulatory support (MCS). This report describes (1) a conceptual model of adjustment to MCS and HRQOL, (2) the development of a new set of items to assess adjustment and HRQOL, and (3) establishes content validity of the new model and items., Methods: We interviewed 15 expert clinicians, 16 patients with advanced HF, and 48 MCS patients. A grounded theory approach was used to systemically examine qualitative data. We developed a coding dictionary, with codes organized under concepts. A conceptual model of adjustment to MCS and HRQOL was developed. A set of relevant items was generated from the codes, concepts, and conceptual model. After items were refined, MCS patients participated in cognitive interviews to provide feedback on their relevance and acceptability., Results: Patients described how having HF and MCS affected their daily lives. Three concepts regarding adjustment to MCS and its relationship to HRQOL emerged: (1) effect of disease and treatment (satisfaction with treatment, symptoms, and self-efficacy regarding self-care), (2) resources, and (3) implant strategy. From our codes, concepts, and model, we developed a set of 652 items that were categorized by concept. The item set was reduced from 652 items to 236 (36%), and 120 of these 236 items (51%) underwent cognitive debriefing. Our final set includes 239 items with evidence of content validity., Conclusions: Our newly developed model on adjustment to MCS and HRQOL and items will undergo further testing in the future., (Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Aortic insufficiency (AI) following rotary left ventricular assist device (LVAD) implantation is an increasingly common problem with inadequately defined treatment options. Percutaneous transcatheter (PTC) closure of the aortic valve (AV) has been described as a potential nonsurgical approach. Alternatively, we present a case of decompensated heart failure due to de novo severe AI following LVAD in which successful PTC closure of the AV resolved the severe AI and allowed for clinical recovery and stability for more than 10 months as a bridge to heart transplantation., (© 2014 Wiley Periodicals, Inc.)

Background: The Ventricular Assist Device for the Treatment of Advanced Heart Failure (ADVANCE) Bridge to Transplant (BTT) trial was a multicenter, prospective trial of the HeartWare Ventricular Assist Device (HVAD). The performance of the HVAD in various demographic sub-groups was evaluated., Methods: Baseline characteristics, adverse events, and survival were compared for men vs. women and whites vs. non-whites in the combined ADVANCE BTT and continued access protocol trial. Of 332 patients enrolled in these trials, 236 were men and 96 women, with 228 whites and 104 non-whites., Results: At baseline, women had a smaller body surface area (1.8 ± 0.2 vs. 2.1 ± 0.3 m2, p < 0.0001), less hypertension (50.0% vs. 61.9%, p = 0.05), and less ischemic cardiomyopathy (15.6% vs. 45.3%, p < 0.0001). Differences in Kaplan-Meier survival were not significant at 180 days (men, 91.8%; women, 91.7%) and 1 year (men, 85.3%; women, 85.1%) despite adjustment for baseline differences. Men had a lower incidence of early right heart failure and renal and respiratory dysfunction, and a shorter length of stay. In the analysis by race, non-whites were younger than whites and had less ischemic heart failure, more hypertension, and lower creatinine levels at baseline. Non-whites had lower rates of arrhythmia, bleeding requiring rehospitalization, and device malfunctions than whites. Survival was high in non-whites and whites, at 94.1% vs. 90.4% at 180 days and 89.2% vs. 82.8% at 1 year, respectively, despite adjustment for baseline differences., Conclusions: Although heart failure etiology differed between men and women and between whites and non-whites, sex and race were not factors that affected survival in patients receiving the HVAD as BTT, which was high in all sub-groups., (Copyright © 2015. Published by Elsevier Inc.)

Background: Severe symptomatic aortic stenosis (AS) is associated with high mortality without intervention. The impact of waiting time for aortic valve replacement (AVR), either surgically or transcatheter, has not been reported., Methods: From January 2008 to December 2012, we identified 1,005 patients with severe symptomatic AS. AVR was recommended for 823 patients (82%). Of these 823 patients, 721 (87.6%) underwent AVR. We modeled overall survival (OS) since AVR recommendation or intervention date using Cox and multistate models., Results: Overall, the median (first, third quartiles) waiting time until operation was 2.9 (1.3, 5.1) weeks. Mortality at these times was lower (p<0.001) in the AVR group (1.2%, 0.3%, 1.7%, respectively) than in the group that did not receive AVR (6.9%, 2.9%, 9.8%, respectively). Thirty-day mortality after AVR was 3.9% (3.2% surgical AVR [SAVR] and 7.0% transcatheter AVR [TAVR]). In patients receiving AVR, waiting time was not associated with increased mortality. Mortality while waiting for AVR was 3.7% and 11.6% at 1 and 6 months, respectively. Mortality while waiting for TAVR was higher than that for SAVR (1-, 6-, and 12-month mortality of 3.7%, 8.0%, and 9.6%, respectively, in SAVR group and 3.8%, 23.3%, and 27.5%, respectively, in TAVR group; p<0.001)., Conclusions: Some patients do not receive AVR in a timely fashion, and prolonged waiting time for AVR is associated with mortality greater than the AVR operative mortality. Although waiting time was not associated with poor operative outcomes after AVR, many patients may die while waiting for AVR. Patients should receive AVR on a semiurgent, not elective, basis., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Few studies have reported on hospital length of stay (LOS) after left ventricular assist device (LVAD) implantation. The purpose of this study was to determine pre- and peri-operative predictors of hospital LOS after LVAD implantation., Methods: We analyzed adult primary continuous-flow LVAD patients implanted between June 23, 2006 and December 31, 2010 at 105 institutions from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). Retrospective analyses included measures of central tendency, frequencies, correlations and stepwise multivariable regression modeling (p ≤ 0.05). Independent variables included demographic characteristics, pre-implant clinical and behavioral variables and concomitant surgery., Results: Characteristics of the patients (n = 2,200) included: mean age 54.6 ± 12.6 years; 79% male; 69% white; 57% INTERMACS Profile 1 or 2; 37% diabetic; 21% with history of coronary artery bypass graft (CABG); 7% with history of valve surgery; and 37% with concomitant surgery. Median hospital LOS (implant to discharge) was 20 days. Significant predictors of an increased hospital LOS included demographic characteristics (older age and non-white), pre-implant clinical variables (history of CABG or valve surgery, diabetes, ascites, INTERMACS Profiles 1 and 2, low albumin, high blood urea nitrogen, high right atrial pressure) and concomitant surgery, explaining 12% variance (F = 22.65, p<0.001)., Conclusions: Demographic characteristics, pre-implant variables and concomitant surgery partially explained hospital LOS after continuous-flow LVAD implant. These variables have implications regarding selection of patients for mechanical circulatory support., (Copyright © 2014 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: Randomized controlled trials of permanent atrial fibrillation ablation surgery have shown improved outcomes compared with control patients undergoing concomitant cardiac surgery. Little has been reported regarding patients with paroxysmal atrial fibrillation. We hypothesized that treating paroxysmal atrial fibrillation during cardiac surgery would not adversely affect the perioperative risk and would improve the midterm outcomes., Methods: From April 2004 to June 30 2012, 4947 patients (excluding those with transcatheter aortic valve implants, left ventricular assist devices, trauma, transplantation, and isolated atrial fibrillation surgery) underwent cardiac surgery, and 1150 (23%) had preoperative atrial fibrillation. Of these, 552 (48%) had paroxysmal atrial fibrillation. Three groups were compared using propensity score matching: treated (n = 423, 77%), untreated (n = 129, 23%), and no atrial fibrillation (n = 3797)., Results: The treated patients had 30-day mortality similar to that of the untreated patients and those without atrial fibrillation. They had fewer perioperative complications (26% vs 46%, P = .001), greater freedom from atrial fibrillation at the last follow-up visit (81% vs 60%, P = .007), and lower mortality (hazard ratio 0.47, P = .007) compared with the untreated patients. Compared with those without atrial fibrillation, the treated patients had fewer perioperative complications (25% vs 48%, P < .001), lower freedom from atrial fibrillation at the last follow-up visit (84% vs 93%, P = .001), and similar mortality., Conclusions: Concomitant surgical ablation of paroxysmal atrial fibrillation was not associated with increased perioperative risk. The treated patients had greater late freedom from atrial fibrillation and midterm survival compared with the untreated patients, and similar midterm survival compared with the patients without atrial fibrillation. These results suggest that paroxysmal atrial fibrillation warrants treatment consideration in select patients undergoing cardiac surgery., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Heart transplantation requires substantial personal, financial, and psychosocial resources. Using an existing multisite data set, we examined predictors of mortality at 5 to 10 years after heart transplantation., Methods: All 555 participants completed a self-report quality of life instrument. Of these patients, 55 (10%) died 5 to 10 years after heart transplantation. Statistical analyses included frequencies, means, Pearson correlation coefficients, and Cox proportional hazard modeling., Results: Educational level and higher levels of social and economic satisfaction were predictive of improved survival. Conversely, married status, more cumulative infections, the presence of hematologic disorders, higher New York Heart Association (NYHA) class, and poor adherence to medical care predicted worse survival., Conclusions: Demographic, clinical, psychosocial, and behavioral factors were important predictors of long-term survival after heart transplantation. These findings have important implications for patient selection for heart transplantation, as well as for posttransplantation care., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The classic cut and sew maze is thought to reduce stroke, in part because of left atrial appendage (LAA) elimination. Multiple LAA elimination techniques have evolved with the introduction of new surgical treatment options for atrial fibrillation (AF), but the impact on stroke remains unknown. We studied the rate of late neurologic event (LNE) in the era of contemporary AF surgery., Methods: From April 21, 2004, to June 30, 2011, 773 patients underwent surgery for AF. In 131 patients, the LAA was excised. In 579, alternative elimination techniques were used (97 external ligation, 313 internal ligation, 126 stapled excision, 23 stapled excision plus internal ligation, 5 internal plus external ligations, and 15 that did not fit into any category); 63 LAAs were left intact and excluded from analyses. Complete follow-up was obtained by medical record review and phone call. Median survival follow-up was 3.3 years (first and third quartiles, 1.6 and 5.0). An LNE was defined as either a documented stroke or transient ischemic attack 30 or more days after surgery. Baseline characteristics and outcomes between LAA techniques were compared using χ(2), Fisher's exact tests, and Student's t tests., Results: There were 25 LNEs (3.5%) overall; the median occurrence time was 3.6 years (first and third quartiles, 1.9 and 5.4) after surgery. There were 17 strokes and 8 transient ischemic attacks. Of 45 demographic and surgical variables, only age, aortic valve surgery, and perioperative neurologic event (<30 days after cardiac surgery) independently predicted LNE (p = 0.003, 0.021, and 0.010, respectively). Late neurologic events occurred with an annual rate of 1.13% in patients with alternative elimination techniques, and 0.20% in patients with excised LAA (p = 0.001). Patients in AF at any time were more likely to have LNE, but this was not an independent predictor., Conclusions: After surgery for AF ablation, there is ongoing low risk of LNE even when the LAA is surgically excised. Further investigation should be pursued to clarify whether a difference exists with alternative elimination techniques and in patients in whom AF is successfully eliminated., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Limited data have suggested that an "obesity paradox" exists for mortality and cardiovascular outcomes in patients undergoing coronary artery bypass grafting. Much less is known about the role of the preoperative body mass index (BMI) in patients undergoing valve surgery. We evaluated 2,640 consecutive patients who underwent valve surgery between April 2004 and March 2011. The patients were classified by the World Health Organization standards as "underweight" (BMI 11.5 to 18.4 kg/m(2), n = 61), "normal weight" (BMI 18.5 to 24.9 kg/m(2), n = 865), "overweight" (BMI 25 to 29.9 kg/m(2), n = 1,020), and "obese" (BMI 30 to 60.5 kg/m(2), n = 694). Mortality was ascertained using the Social Security Death Index. Hazard ratios (HRs), adjusted for known preoperative risk factors, were obtained using Cox regression models. The mean follow-up was 31.9 ± 20.5 months. The long-term mortality rate was 1.21, 0.52, 0.32, and 0.44 per 10 years of person-time for underweight, normal, overweight, and obese patients, respectively. Compared to the normal BMI category, overweight patients (adjusted HR 0.60, 95% confidence interval 0.46 to 0.79, p <0.001) and obese patients (adjusted HR 0.67, 95% confidence interval 0.50 to 0.91, p = 0.009) were at a lower hazard of long-term all-cause mortality. Underweight patients remained at a greater adjusted risk of long-term mortality than normal weight patients (adjusted HR 1.69, 95% confidence interval 1.01 to 2.85, p = 0.048). Similar patterns of mortality outcomes were noted in the subset of patients undergoing isolated valve surgery. In conclusion, overweight and obese patients had greater survival after valve surgery than patients with a normal BMI. Very lean patients undergoing valve surgery are at a greater hazard for mortality and might require more rigorous preoperative candidate screening and closer postoperative monitoring., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of this review is to examine the appropriateness of coronary artery bypass grafting (CABG) for the patient with ischemic cardiomyopathy and congestive heart failure., Recent Findings: CABG is the gold standard therapy for patients with advanced multivessel and left main coronary artery disease. A critical analysis of the Surgical Treatment of Ischemic Heart Failure (STICH) trial confirms the benefit of CABG for patients with ischemic cardiomyopathy., Summary: CABG can be safely applied to patients with heart failure and provides benefit for appropriately selected patients.

Objective: Patients undergoing cardiac surgery with a history of untreated atrial fibrillation have reduced survival compared with similar patients without atrial fibrillation. We sought to compare the midterm survival of patients who received concomitant surgical ablation treatment for atrial fibrillation (atrial fibrillation ablated) with that of matched patients without a history of atrial fibrillation (no atrial fibrillation)., Methods: We evaluated 3262 consecutive patients (813 [25%] with atrial fibrillation and 2449 [75%] without preoperative atrial fibrillation) undergoing cardiac surgery at a single institution from April 2004 to April 2009. Of patients with atrial fibrillation, 565 (70%) were treated with a concomitant surgical ablation procedure. Propensity scores were calculated on the basis of 37 known preoperative risk factors and yielded 744 patients. Midterm survival was compared between patients with atrial fibrillation ablation (n = 372) and patients without atrial fibrillation (n = 372). Survival was also compared between patients with successful vs unsuccessful ablation, and a matched analysis was performed at 1 year between the 2 groups., Results: Mean follow-up was 2.7 ± 1.6 years. Patients without atrial fibrillation and patients with treated atrial fibrillation had similar early 30-day mortality (1.2% vs 0.3%, P = .37) and overall mortality rates (11.6% vs 9.4%, P = .344), respectively. Survival analysis showed no differences at 1, 3, and 5 years between the 2 groups (log-rank P = .22). At last follow-up, 78% of treated patients were free of atrial fibrillation. At 1 year, 68% of patients were free of atrial fibrillation and antiarrhythmic medication. Freedom from atrial fibrillation and antiarrhythmic medication at 1 year predicted improved midterm survival (P = .03) compared with patients in atrial fibrillation or taking antiarrhythmic medication. Propensity-matched analysis after 1 year demonstrated improved survival for patients who were successfully treated (P = .016)., Conclusions: Patients undergoing surgical treatment of atrial fibrillation had survival similar to that of patients without a history of atrial fibrillation. Those with successful sinus restoration had improved survival compared with those who were treated but remained in atrial fibrillation., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Coexistence of aortic disease is an uncommon finding in end-stage heart failure patients requiring left ventricular assist device (LVAD) placement. A 38-year-old man with non-ischemic dilated cardiomyopathy was admitted in stage D heart failure. Preoperative computed tomography demonstrated multiple saccular aneurysms of the ascending aorta and sinus of valsalva. We successfully performed complex aortic surgery and the implantation of a continuous-flow LVAD (HeartWare HVAD) (HeartWare International, Framingham, MA). The postoperative course was uneventful. The patient is currently listed for heart transplantation.

HeartWare continuous flow ventricular assist devices (HVAD) configured as biventricular assist devices maintain diurnal flow variation, lead to end-organ recovery, and provide for a successful bridge-to-heart transplantation in the first successful North American use of continuous flow biventricular assist devices., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Tricuspid regurgitation is common in patients with advanced heart failure. The ideal operative strategy for managing tricuspid valve regurgitation (TR) in patients undergoing left ventricular assist device (LVAD) implantation is unclear. This study was designed to evaluate the effect on outcomes of concomitant tricuspid valve repair (TVR) for moderate to severe (3(+)/4(+)) TR at the time of LVAD implantation., Methods: Patients with >3(+) TR who underwent LVAD implantation from 2005 to 2009 were retrospectively evaluated. Pre-, intra- and post-operative data, including hemodynamics, inotrope requirements and end-organ function parameters, were considered. Outcomes of patients receiving TVR were compared with those who did not receive TVR (NTVR)., Results: Seventy-two LVADs were implanted during the study period. Forty-two (58%) patients had ≥ 3(+) TR prior to LVAD implantation. Eight patients underwent TVR and 34 patients did not undergo TVR (NTVR). There were no significant differences in baseline characteristics or severity of TR between the two groups. The TVR group had a longer cardiopulmonary bypass time (p < 0.01) and required more blood products (p < 0.05). Higher post-operative creatinine and blood urea nitrogen (BUN) values were noted in the TVR group. One patient in the TVR group and 3 patients in the NTVR group required right-sided mechanical assistance (p = 0.6). There was no significant difference in short- or long-term mortality between the two groups., Conclusions: TVR for ≥ 3(+) TR prolonged operative time and showed similar outcomes compared with LVAD implantation alone. A benefit of performing TVR was not demonstrated. As such, TVR may not be necessary at the time of LVAD implantation., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Our study compared health-related quality of life (HRQOL) among cardiac surgical patient groups before and after cardiac operations for isolated surgical procedures and examined cardiac surgical patient HRQOL within the context of United States population norms., Methods: Of 2524 patients undergoing cardiac operations, 370 underwent isolated procedures (coronary artery bypass grafting, 136; aortic valve repair or replacement, 96; mitral valve repair or replacement, 92; Maze procedures, 46) between April 18, 2004, and June 30, 2008. They completed Short Form 36 questionnaires at baseline, at 3, 6, and 12 months postoperatively, and annually thereafter. Statistical analyses included χ(2), analysis of variance, longitudinal modeling, and longitudinal multivariable analyses., Results: Overall, the 370 cardiac surgical patients were 61.5 ± 11.9 years old, 70% men, and 76% white. Significant baseline differences in HRQOL existed among the cardiac surgical groups. Physical and mental components of the Short Form 36 improved from baseline to within 3 to 6 months postoperatively and remained stable through 3 years for all groups. When demographic and clinical covariates were held constant, the effect of cardiac surgical type on postsurgical HRQOL changes was not significant., Conclusions: HRQOL improves early after cardiac operations and remains relatively constant long-term, independently of procedure type., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Statins might have pleiotropic effects, independent of their ability to reduce lipid levels. Recent data have suggested that statins improve early survival and cardiovascular outcomes after coronary artery bypass graft surgery. The effectiveness of statin therapy in normolipidemic cardiac surgery patients is as yet unclear., Methods: We evaluated 3056 consecutive patients who had undergone cardiac surgery between April 2004 and April 2009. Perioperative statin therapy was defined as continued treatment both before (≥ 6 months) and after the index surgery (included as a discharge medication). Hyperlipidemia (HL) was defined as a total cholesterol level greater than 200 mg/dL within 6 months before surgery. Four groups were analyzed: (1) statin-untreated normolipidemic (NL-, n = 1052); (2) statin-treated normolipidemic (NL+, n = 206); (3) statin-untreated hyperlipidemic (HL-, n = 638); and (4) statin-treated hyperlipidemic (HL+, n = 1160) patients. Adjusted hazard ratios accounted for the known preoperative cardiac risk factors. Mortality was ascertained by retrospective database review and the Social Security Death Index., Results: The mean follow-up was 2.2 years. The crude rate of 30-day mortality was 3.0% (32/1052), 0% (0/206), 8.0% (51/638), and 0.7% (8/1160) for the NL-, NL+, HL-, and HL+ groups, respectively. The overall all-cause crude mortality rate was 9.6% (101/1052), 3.9% (8/206), 17.2% (110/638), and 6.5% (75/1160) for the NL-, NL+, HL-, and HL+ groups, respectively. Statin therapy for NL patients undergoing cardiac surgery independently reduced the overall all-cause mortality (adjusted hazard ratio, 0.34; 95% confidence interval, 0.16-0.71; P = .004)., Conclusions: Perioperative statin therapy was associated with reduced mid-term mortality for patients undergoing cardiac surgery, irrespective of their baseline lipid status. This clinical evidence suggests that the beneficial effects of statins might extend beyond their lipid-lowering ability., (Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

A 60-year-old man with end-stage ischemic cardiomyopathy (ejection fraction, 10%) was admitted in cardiogenic shock, which was unresponsive to maximum inotropes and an intraaortic balloon pump. The TandemHeart (TH) left ventricular assist device (Cardiac Assist Inc, Pittsburgh, PA) was placed in the standard percutaneous transseptal configuration with improved hemodynamics. The HeartMate XVE (Thoratec Corp, Pleasanton, CA) implantation was performed as a bridge to transplant 5 days after TandemHeart insertion. The TandemHeart was converted to a temporary right ventricular assist device during the HeartMate XVE (Thoratec Corp) implantation due to right ventricular failure. The right ventricular assist device was weaned 3 days later. This strategy was useful, technically easy, and cost effective.

A 32-year-old man with doxorubicin-induced cardiomyopathy presented in cardiogenic shock. He underwent placement of a Novacor (WorldHeart, Inc., Oakland, CA) left ventricular assist device as a bridge to transplant. Post-operatively he developed a pump pocket infection and dehiscence of his abdominal wound with exposure of the pump. This was treated with irrigation and drainage, antibiotic bead placement and flap closure. Both pre- and post-operative panel-reactive antibodies (PRA) were elevated. He underwent desensitization with intravenous immune globulin (IVIg), rituximab, mycophenolate mofetil and pre-operative plasmapheresis. A donor heart was identified and found to be acceptable by virtual crossmatch. He was transplanted and is doing well with normal graft function at >1 year post-operatively.

Significant tricuspid regurgitation (TR) is present in many patients with heart failure. Valve replacement is necessary in patients in whom the valve is irreparable or in whom there is a high risk of late failure. The following manuscript and videos describe our approach to tricuspid valve replacement with a bioprosthetic valve.

Functional tricuspid regurgitation (TR) is present in many patients with advanced heart failure. The following manuscript and videos describe our approach to its correction.

Heart failure is a tremendous burden on society, and on the health care system in particular. Historically, medical treatments have been the only therapies available because patients were felt to be too high risk to undergo conventional cardiac surgical procedures. Cardiac transplantation remains an established therapy for certain patients with end-stage heart failure but it is limited by donor availability and the need for lifelong immunosuppression. Recent advances in myocardial protection, operative techniques, and perioperative care have made it possible for conventional surgery, such as coronary bypass, ventricular reconstruction, and valve repair, to be offered to many patients with advanced heart failure with good short- and long-term results. In 2005, few patients are inoperable.

Aortic dissection involving the descending aorta has a predictable and often debilitating course of progressive dilatation that occurs once patients survive the acute phase of the disease. Important factors that impact the rate and degree of dilatation include the persistence of a false lumen channel (and the amount of thrombus), the control of hypertension, and the presence of an underlying connective tissue disorder. The mainstay of management of chronic descending aortic dissections is antihypertensive therapy including beta-blockade until the dissected aorta becomes significantly aneurysmal. Surgical management is recommended at that point. Multiple advances have been made that have improved the results of operative repair of aneurysmal descending aortic dissections including circulation management methodologies, CSF drainage, neurocerebral monitoring, and more recently, endovascular therapies. The presentation, diagnosis and management of chronic descending aortic dissections are discussed.

In this retrospective study, we compared the results of 1,283 open cholecystectomies (OCs) performed at our medical center during the pre-laparoscopic era with 1,107 laparoscopic cholecystectomies (LCs) performed from 1990 to 1992. There was no difference in the percentage of cases of acute and chronic cholecystitis in each time period (16.8% in each), nor were there differences in the patient characteristics for each group. The percentage of patients undergoing intraoperative cholangiography was similar for patients with chronic cholecystitis for each period, although the incidence of abnormal cholangiograms was lower in the laparoscopic era (5.8% versus 15.2%, p < 0.001). There was one bile duct injury in the OC group and three in the LC group (although one of these occurred after conversion ot an open procedure), but this difference was not statistically significant. However, there was a higher mortality rate in the patients with acute cholecystitis treated with OC (2.3% versus 0%, p = 0.03) and an increase in the overall complications in the patients with chronic cholecystitis in the OC group (7.5% versus 3.1%, p < 0.001) compared with the LC group. The increase in overall complications appeared to be primarily related to the increased rate of wound-related complications (3.6% versus 0%, p < 0.001) in the patients with chronic cholecystitis in the OC group. LC appears to be a safe procedure with a low incidence of complications including bile duct injury when performed by adequately trained surgeons.