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Objective: To investigate outcomes after aortic root allograft reoperation, identify risk factors for morbidity and mortality, and describe practice evolution since publication of our 2006 allograft reoperation study., Methods: From January 1987 to July 2020, 602 patients underwent 632 allograft-related reoperations at Cleveland Clinic: 144 before 2006 (early era, which suggested radical explant was superior to aortic-valve-replacement-within-allograft [AVR-only]), and 488 from 2006 to present (recent era). Indications for reoperation were structural valve deterioration in 502 (79%), infective endocarditis in 90 (14%), and nonstructural valve deterioration/noninfective endocarditis in 40 (6.3%). Reoperative techniques included radical allograft explant in 372 (59%), AVR-only in 248 (39%), and allograft preservation in 12 (1.9%). Perioperative events and survival were assessed among indications, techniques, and eras., Results: Operative mortality by indication was 2.2% (n = 11) for structural valve deterioration, 7.8% (n = 7) in those with infective endocarditis, and 7.5% (n = 3) for nonstructural valve deterioration/noninfective endocarditis, and by surgical approach 2.4% (n = 9) after radical explant, 4.0% (n = 10) for AVR-only, and 17% (n = 2) for allograft preservation. Operative adverse events occurred in 4.9% (n = 18) of radical explants and 2.8% (n = 7) of AVR-only procedures (P = .2). Patients undergoing radical explants received larger valves than those undergoing AVR-only (median, 25 vs 23 mm)., Conclusions: Aortic root allograft reoperations present a technical challenge but can be performed with low mortality and morbidity. Radical explant offers outcomes similar to AVR-only while allowing for implant of larger prostheses. Increasing experience with allograft reoperations has permitted excellent outcomes; thus, risk of reoperation should not dissuade surgeons from using allografts for invasive aortic valve infective endocarditis and other indications., (Copyright © 2023. Published by Elsevier Inc.)

Background:  As risks of repairing the descending thoracic and thoracoabdominal aorta diminish, common complications that may prolong hospital stay, or actually increase risk, require attention. One such complication is postoperative atrial fibrillation (AF). Therefore, we characterized prevalence of, risk factors for, and effects of postoperative atrial fibrillation (PoAF) after descending and thoracoabdominal aorta repair., Methods:  From January 2000 to January 2011, 696 patients underwent open descending or thoracoabdominal aorta repair at Cleveland Clinic. Operations approached via median sternotomy ( n  = 178) and patients treated preoperatively for arrhythmias (32 amiodarone, 9 paced) or in AF on preoperative electrocardiogram ( n  = 14) were excluded, leaving 463. Logistic regression analysis identified risk factors for PoAF. Temporal relation of PoAF with postoperative morbidities was determined, and outcomes following PoAF were compared between propensity-matched pairs., Results:  New-onset PoAF occurred in 101 patients (22%) at a median 68 hours of postincision. Risk factors included older age ( p =  0.002) and history of remote AF ( p =  0.0004) but not operative details, such as pericardiotomy for cardiac cannulation. Hypoperfusion and neurologic complications tended to precede PoAF, whereas sepsis, respiratory failure, and dialysis followed. Among 94 propensity-matched patient pairs, those developing PoAF were more likely to experience hypoperfusion ( p =  0.006), respiratory failure ( p =  0.009), dialysis ( p =  0.04), paralysis ( p  < 0.0001), longer intensive care unit stay (median 7 vs. 5 d, p =  0.02), and longer postoperative hospital stay (median 15 vs. 13 d, p =  0.004). However, hospital death was similar (6/94 PoAF [6.4%] vs. 7/94 no PoAF [7.4%], p =  0.8)., Conclusion:  PoAF after descending thoracic aorta surgery is relatively common and a part of a constellation of other serious complications prolonging postoperative recovery. While PoAF was associated with adverse events, it did not impact postoperative cost and mortality. Descending thoracic aorta surgery is by itself comorbid enough, which is likely why PoAF does not have a more significant effect on postoperative recovery and cost., Competing Interests: Eric E. Roselli, MD is a consultant for Artivion, Edwards, Gore, Medtronic, Terumo Aortic. The other authors declare no conflict of interest related to this article., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Objectives: Infection is an important cause of morbidity and mortality after lung transplantation. Immunoglobulins are part of both seromucous (IgA) and serum (IgG) infection defense mechanisms. We therefore hypothesized that lower pretransplant IgA levels would be associated with more early post-lung transplant seromucous infections and greater mortality independent of IgG., Methods: From January 2000 to July 2010, 538 patients undergoing primary lung transplantation had pretransplant IgA (n = 429) and IgG (n = 488) measured as a clinical routine. Median IgA was 200 mg·dL -1 (2% < 70 mg·dL -1 , lower limit of normal); median IgG was 970 mg·dL -1 (5% < 600 mg·dL -1 ). Intensive microbiology review was used to categorize infections and their causative organisms within the first posttransplant year., Results: In total, 397 seromucous infections were observed in 247 patients, most bacterial. Although IgA and IgG were moderately correlated (r = 0.5, P < .0001), low pretransplant IgA was a strong risk factor (P = .01) for seromucous infections, but pretransplant IgG was not (P ≥ .6). As pretransplant IgA levels fell below 200 mg·dL -1 , the risk of these posttransplant infections rose nearly linearly. Lower pretransplant levels of IgA were associated with greater posttransplant mortality to end of follow-up (P = .004), but pretransplant IgG was not (P ≥ .3)., Conclusions: Low levels of preoperative IgA, an important immunoglobulin involved in mucosal immunologic defense, but not IgG, are associated with seromucous infections in the year after lung transplantation and increased follow-up mortality. It would appear prudent to identify patients with relative IgA deficiency at listing and to increase vigilance of monitoring for, and prophylaxis against, seromucous infection in this high-risk population., (Copyright © 2018. Published by Elsevier Inc.)

Background: We hypothesized that factors associated with an institution's residual risk unaccounted for by population-based models may be identifiable and used to enhance the value of population-based risk scores for quality improvement., Methods: From January 2000 to January 2010, 4,971 patients underwent aortic valve replacement (AVR), either isolated (n = 2,660) or with concomitant coronary artery bypass grafting (AVR+CABG; n = 2,311). Operative mortality and major morbidity and mortality predicted by The Society of Thoracic Surgeons (STS) risk models were compared with observed values. After adjusting for patients' STS score, additional and refined risk factors were sought to explain residual risk. Differences between STS model coefficients (risk-factor strength) and those specific to our institution were calculated., Results: Observed operative mortality was less than predicted for AVR (1.6% [42 of 2,660] vs 2.8%, p < 0.0001) and AVR+CABG (2.6% [59 of 2,311] vs 4.9%, p < 0.0001). Observed major morbidity and mortality was also lower than predicted for isolated AVR (14.6% [389 of 2,660] vs 17.5%, p < 0.0001) and AVR+CABG (20.0% [462 of 2,311] vs 25.8%, p < 0.0001). Shorter height, higher bilirubin, and lower albumin were identified as additional institution-specific risk factors, and body surface area, creatinine, glomerular filtration rate, blood urea nitrogen, and heart failure across all levels of functional class were identified as refined risk-factor variables associated with residual risk. In many instances, risk-factor strength differed substantially from that of STS models., Conclusions: Scores derived from population-based models can be enhanced for institutional level use by adjusting for institution-specific additional and refined risk factors. Identifying these and measuring differences in institution-specific versus population-based risk-factor strength can identify areas to target for quality improvement initiatives., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to understand the factors modulating left heart reverse remodeling after aortic valve replacement, the relationship between the preoperative symptoms and modulators of left heart remodeling, and their influence on long-term survival., Methods: From October 1991 to January 2008, 4264 patients underwent primary aortic valve replacement for aortic stenosis. Changes in the time course of left ventricular reverse remodeling were assessed using 5740 postoperative transthoracic echocardiograms from 3841 patients., Results: Left ventricular hypertrophy rapidly declined after surgery, from 137 ± 42 g/m(2) preoperatively to 115 ± 27 by 2 years and remained relatively constant but greater than the upper limit of normal. The most important risk factor for residual left ventricular hypertrophy was greater preoperative left ventricular hypertrophy (P < .0001). Other factors included a greater left atrial diameter (reflecting diastolic dysfunction), a lower ejection fraction, and male gender. An increased postoperative transprosthesis gradient was associated with greater residual left ventricular hypertrophy; however, its effect was minimal. Preoperative severe left ventricular hypertrophy and left atrial dilatation reduced long-term survival, independent of symptom status., Conclusions: Severe left ventricular hypertrophy with left atrial dilatation can develop from severe aortic stenosis, even without symptoms. These changes can persist, are associated with decreased long-term survival even after successful aortic valve replacement, and could be indications for early aortic valve replacement if supported by findings from an appropriate prospective study., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: To study the effect of mitral valve repair with or without concomitant tricuspid valve repair on functional tricuspid regurgitation and right ventricular function., Methods: From 2001 to 2007, 1833 patients with degenerative mitral valve disease, a structurally normal tricuspid valve, and no coronary artery disease underwent mitral valve repair, and 67 underwent concomitant tricuspid valve repair. Right ventricular function (myocardial performance index and tricuspid annular plane systolic excursion) was measured before and after surgery using transthoracic echocardiography for randomly selected patients with tricuspid regurgitation grade 0, 1+, and 2+ (100 patients for each grade) and 93 with grade 3+/4+, 393 patients in total., Results: In patients with mild (<3+) preoperative tricuspid regurgitation, mitral valve repair alone was associated with reduced tricuspid regurgitation and mild worsening of right ventricular function. Tricuspid regurgitation of 2+ or greater developed in fewer than 20%, and right ventricular function had improved, but not to preoperative levels, at 3 years. In patients with severe (3+/4+) preoperative tricuspid regurgitation, mitral valve repair alone reduced tricuspid regurgitation and improved right ventricular function; however, tricuspid regurgitation of 2+ or greater returned and right ventricular function worsened toward preoperative levels within 3 years. Concomitant tricuspid valve repair effectively eliminated severe tricuspid regurgitation and improved right ventricular function. Also, over time, tricuspid regurgitation did not return and right ventricular function continued to improve to levels comparable to that of patients with lower grades of preoperative tricuspid regurgitation., Conclusions: In patients with mitral valve disease and severe tricuspid regurgitation, mitral valve repair alone was associated with improved tricuspid regurgitation and right ventricular function. However, the improvements were incomplete and temporary. In contrast, concomitant tricuspid valve repair effectively and durably eliminated severe tricuspid regurgitation and improved right ventricular function toward normal, supporting an aggressive approach to important functional tricuspid regurgitation., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: The study objective was to correlate the degree of tricuspid regurgitation with clinical indicators of right-sided heart failure and both qualitative and quantitative measures of right-sided heart morphology and function in patients with degenerative mitral valve disease., Methods: From 2001 to 2007, 1833 patients with degenerative mitral valve disease, structurally normal tricuspid valve, and no coronary artery disease underwent surgery. Right-sided heart morphology (right ventricular base-to-apex length, tethering distance and area, and right atrial systolic area) and right ventricular function (tricuspid annular plane systolic excursion, myocardial performance index, and tricuspid valve annular shortening) were measured on preoperative transthoracic echocardiograms for 100 randomly selected patients from each of tricuspid regurgitation grades 0, 1+, and 2+, and for all 93 patients with tricuspid regurgitation grade 3+/4+. Multivariable regression was used to evaluate the association of left- and right-sided heart morphology and function with tricuspid regurgitation., Results: Increasing tricuspid regurgitation grade was associated with higher right ventricular pressure (P < .0001), increased tethering distance (P = .008), larger right atrial size (P = .0002), and worsening right ventricular function, particularly when 3+/4+ tricuspid regurgitation was present. When tricuspid regurgitation was 3+/4+, both tricuspid annular plane systolic excursion and myocardial performance index were almost certainly abnormal. Changes in right-sided heart morphology and right ventricular dysfunction were synergistic in relation to severity of tricuspid regurgitation., Conclusions: Functional tricuspid regurgitation accompanying mitral valve disease is associated with proportional changes in right-sided heart morphology; however, severe tricuspid regurgitation is nearly always associated with right ventricular dysfunction, suggesting a synergistic relationship. Right ventricular dysfunction is likely as important as tricuspid regurgitation because it offers an explanation for the negative prognostic impact of tricuspid regurgitation and has implications for the clinical management of patients., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Less invasive approaches to aortic valve surgery are increasingly used; however, few studies have investigated their impact on outcome. We sought to compare clinical outcomes after these approaches with full sternotomy using propensity-matching methods., Methods: From January 1995 to January 2004, a total of 2689 patients underwent isolated aortic valve surgery, 1193 via upper J-hemisternotomy and 1496 via full sternotomy. Because of important differences in patient characteristics between these groups, a propensity score based on 42 variables was used to obtain 832 well-matched patient pairs (70% of possible cases)., Results: In-hospital mortality was identical for propensity-matched patients, 0.96% (8 in each). Occurrences of stroke (P > .9), renal failure (P = .8), and myocardial infarction (P = .7) were similar. However, 24-hour mediastinal drainage was a third less after less invasive surgery (median, 250 vs 350 mL; P < .0001), and fewer patients received transfusions (24% vs 34%; P < .0001). More patients undergoing less invasive surgery were extubated in the operating room (12% vs 1.6%; P < .0001), postoperative forced 1-second expiratory volume was higher (P = .009), and fewer had respiratory failure (P = .01). Early after operation, pain scores were lower (P < .0001) after less-invasive surgery and postoperative length of stay shorter (P < .0001)., Conclusions: Within that portion of the spectrum of isolated aortic valve surgery where propensity matching was possible, minimally invasive aortic valve surgery had not only cosmetic advantages, but blood product use, respiratory, pain, and resource utilization advantages over full sternotomy, and no apparent detriments. Less invasive aortic valve surgery should be considered for most aortic valve operations., (Copyright © 2012. Published by Mosby, Inc.)

Objectives: Guidelines recommend antibiotic prophylaxis 60 minutes before skin incision; however, it is unclear whether more precise timing would further reduce sternal wound infection. Our objectives were to examine the relationship between antibiotic timing and infection, test potential efficacy of optimal antibiotic timing in preventing infection, and determine whether patient comorbidity is related to timing and infection., Methods: From 1/1/1995-1/1/2008, 28,250 patients underwent 28,702 cardiac surgical procedures involving a median sternotomy; 85% received only cefuroxime and 15% received only vancomycin prophylaxis. Multivariable analysis identified factors associated with infection within each phase, and risk-adjusted optimal timing was determined using patient data, risk variables, and hypothetical values of antibiotic timing., Results: Prevalence of sternal wound infection was 2.0% (489 patients) for cefuroxime and 2.3% (101 patients) for vancomycin. Minimum prevalence for infection was 1.8% observed when cefuroxime was administered 15 minutes before incision; risk increased to 2.2% with administration more than 45 minutes before incision and to 2.8% at 60 minutes before incision. Minimum prevalence of infection in patients who received vancomycin was 1.8% observed with initiation 32 minutes before incision; risk increased to 2.2% for administration 45 minutes before incision and 3.2% with administration 60 minutes before incision. Simulation for optimal timing found that it was influenced by phase-specific risk factors., Conclusions: Refining current antibiotic prophylaxis guidelines may lower sternal wound infections. Antibiotic administration timing resulting in lowest likelihood for infection varied with antibiotic and patient-specific factors. Optimal risk-adjusted timing could potentially reduce infections by 9%-31%., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Our objective was to compare effectiveness and safety of a simplified approach for removing retroperitoneal tumors with extensive cavoatrial involvement using beating-heart cardiopulmonary bypass (CPB) versus hypothermic circulatory arrest (HCA)., Methods: From January 1984 to January 2009, 144 patients underwent radical nephrectomy and inferior vena caval tumor thrombectomy, 56 (39%) using CPB and 88 (61%) HCA. Compared with HCA patients, CPB patients were of similar age (62 ± 10 vs 60 ± 11 years, P = .4) and gender (39% vs 39% female, P > .9), with similar stroke history (3.6% vs 2.3%, P =.6), but had less pulmonary disease (18% vs 33%, P = .06) and lower preoperative creatinine concentration (1.3 ± 0.72 vs 1.5 ± 0.86 mg · dL(-1), P = .04)., Results: Complete tumor removal was achieved in all patients by both strategies. Compared with HCA procedures, CPB times were shorter (50 ± 33 vs 94 ± 40 minutes, P < .0001). CPB patients required fewer blood transfusions (36% no transfusion vs 17%, and 45% ≥4 units vs 72%; P = .003) and had no statistical difference in morbidity, including reoperation for bleeding (3.8% vs 8.0%, P = .3), renal failure requiring dialysis (3.6% vs 10%, P = .14), respiratory insufficiency (21% vs 19%, P = .8), sepsis (5.4% vs 10%, P = .3), stroke (5.4% vs 1.1%, P = .13), and in-hospital mortality (7.1% vs 13%, P = .3). Ten-year survival (22% vs 22%, P > .9) and freedom from cancer recurrence (24% vs 28%, P = .8) were similar., Conclusions: Radical nephrectomy and removal of inferior vena caval tumor-thrombus can be simply, effectively, and safely performed with beating-heart CPB, avoiding the deleterious effects of HCA and providing clinical benefit without increasing morbidity or mortality., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: An array of neuroprotective strategies has evolved to limit spinal cord injury during descending thoracic aneurysm and thoracoabdominal aortic aneurysm repair. This study prospectively assessed the neuroprotective impact of intrathecal papaverine added to other techniques in aortic aneurysm repairs., Methods: From January 2002 to January 2010, 398 consecutive patients underwent descending thoracic aneurysm and thoracoabdominal aortic aneurysm repairs at Cleveland Clinic, 68 under hypothermic circulatory arrest. We focused on the remaining 330, in whom a combination of neuroprotective adjuncts was used intraoperatively to mitigate spinal cord ischemia. These included distal aortic perfusion with moderate hypothermia, cerebrospinal fluid drainage, and intrathecal papaverine. Two patient groups were discriminated according to whether intrathecal papaverine was (n = 250) or was not (n = 80) administered. Postoperative outcomes were analyzed from a prospectively maintained clinical database., Results: Preoperative patient characteristics and comorbidities were similar between groups. Extent of aortic disease was also similar: descending thoracic aneurysm (34% with papaverine vs 28%) and Crawford types I (25% vs 34%), II (27% vs 24%), III (13% vs 13%), and IV (2% vs 2.5%). Groups had similar in-hospital mortality (6.4% vs 11%; P = .11) and permanent stroke (4.4% vs 7.5%; P = .3). Permanent paraplegia (3.6% vs 7.5%; P = .01) and paraparesis (1.6% vs 6.3%; P = .01) were significantly lower in the intrathecal papaverine group., Conclusions: Adding intrathecal papaverine to the neuroprotective protocol for descending thoracic aneurysm and thoracoabdominal aortic aneurysm repairs may enhance spinal cord perfusion and provide additional spinal cord protection., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The risk of death and complications of infective endocarditis (IE) treated medically has to be balanced against those from surgery in constructing a therapeutic approach. Recent literature has drawn conflicting conclusions on the benefit of surgery for IE. We reviewed patients treated surgically for IE at the Cleveland Clinic from 2003 to 2007 to examine their outcomes., Methods: A retrospective review of consecutive patients who underwent surgery for native and prosthetic valve endocarditis between January 1, 2003, and December 31, 2007, was conducted. Surgical outcomes were reviewed to include survival and postoperative complications. Survival was evaluated at end of hospital stay, 30 days, 1 year, and at last follow-up., Results: Four hundred twenty-eight patients underwent surgery for IE during the study period: 248 (58%) had native valve endocarditis and 180 (42%) had prosthetic valve endocarditis. Overall 90% of patients survived to hospital discharge. When compared with patients with native valve infection, patients with prosthetic infection had significantly higher 30-day mortality (13% versus 5.6%; p<0.01), but long-term survival was not significantly different (35% versus 29%; p=0.19). Patients with IE caused by Staphylococcus aureus had significantly higher hospital mortality (15% versus 8.4%; p<0.05), 6-month mortality (23% versus 15%; p=0.05), and 1-year mortality (28% versus 18%; p=0.02) compared with non-S aureus IE., Conclusions: Surgical treatment of IE was associated with 90% hospital survival. Outcomes within the 30 days were better for native valve than for prosthetic valve endocarditis. Long-term outcomes were similar. Finally, S aureus was associated with significantly higher mortality compared with other pathogens., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Uncertainty about long-term effects of surgically unaddressed moderate (2+) secondary tricuspid valve (TV) regurgitation (TR) accompanying left-sided degenerative heart valve disease led us to identify reasons for and factors associated with TV repair, compare safety and clinical effectiveness of relieving TR, and identify factors associated with severe (3/4+) postoperative TR., Methods: From 1997 to 2008, 1,724 patients with 2+ TR underwent 830 mitral, 703 aortic, and 191 double-valve procedures; 91 (5%) had concomitant TV repair. Logistic regression analysis was used to identify factors associated with TV repair and for propensity-matched comparison of safety (in-hospital morbidity, mortality) and effectiveness of TV repair (longitudinal echocardiographic assessment of postoperative TR and New York Heart Association class, TV intervention, survival)., Results: Factors associated with TV repair of 2+ TR included larger right ventricles and left ventricles (p<0.001), greater TV tethering height (p=0.0002), and prior concurrent mitral valve procedures (p≤0.004). In-hospital complications, subsequent TV interventions, and intermediate-term survival were similar for matched patients. The TV repair patients had less 3/4+ TR at discharge (7% versus 15%), sustained out to 3 years. No TV repair (p=0.05), female sex (p<0.0001), and mitral valve replacement (p=0.008) were associated with 3/4+ TR., Conclusions: A TV repair for moderate TR concomitant with surgery for degenerative left-sided heart valve disease is reasonable to provide an opportunity to prevent its progression and development of right ventricle dysfunction, particularly for patients with important right ventricle remodeling and evidence of right ventricular failure, and for patients with advanced left-sided disease requiring mitral valve replacement., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Mechanical circulatory support (MCS) may be used for severe graft failure after heart transplantation, but the degree to which it is lifesaving is uncertain., Methods: Between June 1990 and December 2009, 53 patients after 1417 heart transplants (3.7%) required post-transplant MCS for acute rejection (n=17), biventricular failure (n=16), right ventricular failure (n=16), left ventricular failure (n=1), or respiratory failure (n=3). Although support was occasionally instituted remotely post-transplant (5>1 year), in 39 (73%) instances it was required within 1 week. Initial mode of support was extracorporeal membrane oxygenation in 43 patients (81%), biventricular assist device in 4 (7.5%), and right ventricular assist device in 6 (11%)., Results: Risk of requiring respiratory support was highest in those with restrictive cardiomyopathy as indication for transplant, women, and those with elevated pulmonary pressure or renal failure. Complications of support, which increased progressively with its duration, included stroke in two patients (3.8%), infection in two (3.8%), and reoperation for bleeding (seven instances) in four (7.0%). Nineteen patients (36%) recovered and were removed from support, five (9.4%) underwent retransplantation (four after biventricular failure and one after acute rejection), and 29 died while on support (55%). Overall survival after initiating support was 94%, 83%, 66%, and 43% at 1, 3, 7, and 30 days, respectively. Patients requiring support for biventricular failure had better survival than those having acute rejection or other indications (P=0.03). Survival after retransplantation or removal from support following recovery was 88% at 1 year and 61% at 10 years., Conclusion: Severe refractory heart failure after transplantation is a rare catastrophic event for which MCS offers the possibility of recovery or bridge to retransplantation, particularly for patients with biventricular failure in the absence of rejection. Early retransplantation should be considered in patients who show no evidence of graft recovery on MCS.

Background: Many centers are reticent to list patients for liver transplantation until coexistent cardiac disease is surgically corrected. Previous studies have documented considerable morbidity and mortality in liver failure patients undergoing cardiac operations. This study examined whether elective cardiac operations at the time of hepatic transplantation would yield enhanced outcomes., Methods: Between July 1999 and June 2010, 10 patients underwent simultaneous liver transplantation and elective cardiac operations at a single institution. Postoperative outcomes were analyzed using a prospectively maintained database., Results: The 10 patients were men (mean age, 59.8 ± 8.3 years): 7 were in Child-Pugh class B and 3 were in class C. Mean Model for End-Stage Liver Disease score was 17.0 ± 5.8. Cardiac operations included coronary artery bypass grafting in 1, aortic valve replacement in 4, coronary artery bypass grafting and aortic valve replacement in 3, coronary artery bypass grafting and mitral valve repair in 1, and tricuspid valve repair in 1. In-hospital mortality was 20%. Mean postoperative length of stay was 23 ± 8 days. Actuarial survival at 3 years was 70%., Conclusions: Survival was modestly improved relative to that observed in previous studies of advanced liver failure patients undergoing heart operations without concomitant hepatic replacement. Moreover, the medium-term survival outcomes approach those documented with liver transplant alone. Further studies are warranted with this combined surgical strategy to determine if such an approach would be routinely preferable to staged repair of cardiac pathology and liver transplant., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Aim of the Study: The risk of reoperation and loss of a second native valve is a major drawback of the Ross operation. The study aim was to examine the indications, pathologies, procedures, and outcomes for reoperation after the Ross procedure, emphasizing the potential for autograft salvage., Methods: Between 1994 and 2009, a total of 60 reoperations was performed on 55 patients who previously had undergone the Ross procedure. Attention was focused on 49 patients with first-time reoperation for autograft or allograft-related problems (37 males, 12 females; mean age 49 +/- 14 years). At the original operation, 23% of patients had a history of endocarditis, 14% a previous valve replacement, and 61% a bicuspid aortic valve. The original implant technique was full root in 88% of cases, inclusion root in 2%, or subcoronary implant in 9%. Autograft and aortic indications (n = 38) included root and ascending aorta dilatation (53%), structural valve cusp deterioration (32%), endocarditis (11%), and technical failure (5%). Regurgitation was moderate to severe in 97% of cases. Pulmonary indications (n = 21) were allograft degeneration (71%), endocarditis (10%), and Ross reversal (19%). The autograft and aorta reoperation procedures (n = 38) included ascending aorta replacement (n = 2), David reimplantation (n = 1), valve repair (n = 2), valve replacement (n = 13), and root replacement (n = 22). Pulmonary valve replacements (n = 21) were with pulmonary allograft in 12 cases and autograft (Ross reversal) in nine. Twelve of the pulmonary valve replacement group, including the Ross reversals, were combined aortic and pulmonary. During the last 13 reoperations, only two autografts were lost, both of which were potentially salvageable., Results: No intraoperative adverse events or postoperative deaths occurred, and minimal morbidity was observed. During the follow up period there was one death, while two patients required reoperation (one for endocarditis and one non-valve-related)., Conclusion: Reoperation at up to 12 years after a Ross procedure was most commonly required for autograft failure, and less often for allograft degeneration. Of reassurance to prospective Ross patient was the finding that reoperation can be performed safely, and that the autograft can be salvaged either by repair and valve-sparing reimplantation in the aortic position, or by Ross reversal.

Objectives: Gastroesophageal reflux disease (GERD) is implicated as a risk factor for bronchiolitis obliterans syndrome after lung transplantation, but its effects on acute rejection, early allograft function, and survival are unclear. Therefore, we sought to systematically understand the time-related impact of pretransplant GERD on graft function (spirometry), mortality, and acute rejection early after lung transplantation., Methods: From January 2005 to July 2008, 215 patients underwent lung transplantation; 114 had preoperative pH testing, and 32 (28%) had objective evidence of GERD. Lung function was assessed by forced 1-second expiratory volume (FEV(1); percent of predicted) in 97 patients, mortality by follow-up (median, 2.2 years), and acute rejection by transbronchial biopsy., Results: Pretransplant GERD was associated with decreased FEV(1) early after lung transplantation (P = .01) such that by 18 months, FEV(1) was 70% of predicted in double lung transplant patients with GERD versus 83% among non-GERD patients (P = .05). A similar decrease was observed in single lung transplantation (50% vs 60%, respectively; P = .09). GERD patients had lower survival early after transplant ( P = .02)-75% versus 90%. Presence of GERD did not affect acute rejection (P = .6)., Conclusions: For lung transplant recipients, pretransplant GERD is associated with worse early allograft function and survival, but not increased acute rejection. The compromise in lung function is substantial, such that FEV(1) after double lung transplant in GERD patients approaches that of single lung transplant in non-GERD patients. We advocate thorough testing for GERD before lung transplantation; if identified, aggressive therapy early after transplant, including fundoplication, may prove efficacious., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Etiology for increased morbidity in patients (2% to 8%) undergoing reoperation for bleeding after cardiac surgery is unclear. Recent work suggests that it may be related to red-cell transfusion, but what role does reoperation itself play? We sought to determine prevalence of and risk factors for reoperation for bleeding, separate the effect of reoperation from that of transfusion on hospital mortality and major morbidity, and identify the source of bleeding., Methods: From January 1, 2000 to January 1, 2010, 18,891 primary and repeat coronary artery bypass grafting, valve, or combined operations were performed. Risk factors for reoperation were identified by multivariable logistic regression. Hospital mortality and major morbidity were compared in propensity-matched patients requiring reoperation and not. Medical records from 2005 to 2010 were reviewed to determine bleeding source., Results: A total of 566 patients (3.0%) underwent reoperation for bleeding, with considerable variability over time. Risk factors included older age, higher acuity, greater comorbidity, aortic valve surgery, longer myocardial ischemic and cardiopulmonary bypass durations, and surgeon. Mortality was higher for propensity-matched patients requiring reoperation; 8.5% (68% confidence interval [CI] 7.3% to 9.9%) versus 1.8% (CI 1.2% to 2.5%). Both greater transfusion and reoperation were independently associated with increased risk of mortality and major morbidity. At reoperation, technical factors (74%), coagulopathy (13%), both (10%), or other (3.3%) causes were responsible for bleeding., Conclusions: Transfusion and reoperation for bleeding both contribute to postoperative mortality and morbidity. Technical reasons are at the root of most bleeding, emphasizing a major focus for process improvement to minimize need for reoperation and blood use., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Acute rejection (AR) after lung transplantation (LTx) impacts survival and quality of life. The objective of this study, therefore, was to identify risk factors for AR after LTx, focusing on donor- and recipient-specific factors, operative variables, and immunologic issues, including pretransplant panel-reactive antibody (PRA) levels, and donor-recipient human leukocyte antigen (HLA) mismatch., Methods: From March 1996 to November 2007, 481 adults undergoing LTx had 3237 serial transbronchial biopsy specimens that were evaluated for perivascular rejection (grade A0 to A4). Longitudinal analysis was used to characterize the prevalence of rejection grade and influence of donor, recipient, technical, and immunologic variables., Results: AR was highest (54%≥A1) in the first 2 months after LTx, decreased at 6 months (16%≥A1), then remained steady. Prevalence of AR at any time was dominated by donor-specific factors of young age (p<0.0001), blunt trauma (p=0.008), and nonblack race (p=0.012) and by recipient class II PRA exceeding 10% (p=0.005). AR within 2 months was associated with HLA mismatch at the DR locus (p=0.0006) and use of non-O blood-group donors (p=0.008). AR at 4 years and longer after LTx was associated with HLA mismatch at the B locus (p=0.01)., Conclusions: Only a few recipient and operative factors were identified for AR after LTx. Moderately sensitized recipients identified by class II PRA exceeding 10% and those with HLA mismatches at the B and DR loci appear to be more susceptible to AR; however, such immunologic variations appear to be well controlled with current donor selection and immunosuppression protocols. The impact of donor-specific variables on AR is surprisingly strong and warrants closer inspection., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Understanding recurrence of surgically "cured" stage I adenocarcinoma of the lung is important given expected benefits of adjuvant therapy for advanced disease. Therefore, this study characterizes cancer recurrence and its risks, assesses survival after recurrence, and contextualizes overall survival and its risks., Methods: From 1991 to 2001, 285 patients underwent resection of stage I adenocarcinoma (pathologic) of the lung. They were followed cross-sectionally for evidence of cancer recurrence (mean follow-up 7.7 ± 4.3 years). Risk factors for recurrence and all-cause mortality were sought among demographic, medical history, cancer pathology, and surgical procedure data., Results: Cancer recurred in 99 patients. Freedom from recurrence was 92%, 72%, and 57% at 1, 5, and 10 years. Two phases of risk were found: an early hazard phase and an essentially constant late phase after 5 years, with recurrences equally distributed. Early recurrence was associated with larger tumor size in patients who did not undergo mediastinal lymphadenectomy (p = 0.004). Late recurrence was more common in patients with higher pack-years of smoking (p = 0.007). Survival after recurrence was 40% and 17% at 1 and 5 years. Overall survival (65% and 40% at 5 and 10 years) depended not only on variables related to cancer recurrence, but also those of vitality (older age, pulmonary dysfunction, postpneumonectomy state)., Conclusions: Stage I adenocarcinoma of the lung recurs. Identifying high-risk patients will simplify decision making for adjuvant therapy and surveillance. Thorough mediastinal lymphadenectomy dissociates tumor size as a predictor of survival and may itself provide an important survival benefit., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The American College of Cardiology/American Heart Association practice guidelines recommending surgery for asymptomatic patients with severe mitral regurgitation caused by degenerative disease remain controversial. This study examined whether delaying surgery until symptoms occur causes adverse cardiac changes and jeopardizes outcome., Methods: From January 1985 to January 2008, 4,586 patients had primary isolated mitral valve surgery for degenerative mitral regurgitation; 4,253 (93%) underwent repair. Preoperatively, 30% were in New York Heart Association (NYHA) class I (asymptomatic), 56% in class II, 13% in class III, and 2% in class IV. Multivariable analysis and propensity matching were used to assess association of symptoms (NYHA class) with cardiac structure and function and postoperative outcomes., Results: Increasing NYHA class was associated with progressive reduction in left ventricular function, left atrial enlargement, and development of atrial fibrillation and tricuspid regurgitation. These findings were evident even in class II patients (mild symptoms). Repair was accomplished in 96% of asymptomatic patients, and in progressively fewer as NYHA class increased (93%, 86%, and 85% in classes II to IV, respectively; p < 0.0001). Hospital mortality was 0.37%, but was particularly high in class IV (0.29%, 0.20%, 0.67%, and 5.1% for classes I to IV, respectively; p = 0.004). Although long-term survival progressively diminished with increasing NHYA class, these differences were largely related to differences in left ventricular function and increased comorbidity., Conclusions: In patients with severe degenerative mitral regurgitation, the development of even mild symptoms by the time of surgical referral is associated with deleterious changes in cardiac structure and function. Therefore, particularly because successful repair is highly likely, early surgery is justified in asymptomatic patients with degenerative disease and severe mitral regurgitation., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Techniques employed today concomitantly with left-sided heart valve surgery address secondary tricuspid valve regurgitation at 3 anatomic levels-annulus, commissure, and leaflet-although success of these alone or in combination in eliminating tricuspid regurgitation is uncertain. Our objective was to assess the comparative effectiveness of these techniques in reducing or eliminating secondary tricuspid regurgitation., Methods: From 1990 to 2008, 2277 patients underwent tricuspid valve procedures for secondary tricuspid regurgitation concomitantly with mitral (n = 1527, 67%), aortic (n = 180, 7.9%), or combined (n = 570, 25%) valve surgery. These included annulus (flexible prosthesis [n = 1052, 46%], rigid prosthesis [standard = 387, 3-dimensional = 197; 26%], Peri-Guard annuloplasty [Synovis Surgical Innovations, St Paul, Minn; n = 185, 8.1%], and De Vega suture [n = 129, 5.7%]), commissure (Kay [n = 248, 11%]), and leaflet (edge-to-edge suture [n = 79, 3.5%] +/- annulus or commissural) procedures. A total of 4745 postoperative transthoracic echocardiograms in 1965 patients were analyzed., Results: By 3 months after surgery, only 32% of patients overall had no tricuspid regurgitation. However, by 5 years, this had decreased to 22%, and 3+/4+ tricuspid regurgitation had increased from 11% at 3 months to 17%. Patients with rigid ring annuloplasty alone, either standard or 3-dimensional, had the least increase of 3+/4+ tricuspid regurgitation (to 12% at 5 years) compared with either a commissural or leaflet procedure., Conclusion: Rigid prosthetic ring annuloplasty, standard or 3-dimensional, provides early and sustained reduction of tricuspid regurgitation secondary to left-sided valve disease without need for an additional leaflet procedure. However, results are imperfect, possibly because other anatomic levels (subvalvular, papillary muscle, and right ventricular) contributing to its pathophysiology are unaddressed., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Few data support current guidelines for donor selection in lung transplantation. We determined degree of compliance with current donor guidelines, effect of these and variances on survival, and other donor factors predicting survival., Methods: From July 1999 to June 2008, 10,333 primary transplants were performed in the US, with United Network for Organ Sharing data available for age, ABO type, chest radiograph, arterial difference in partial pressure of oxygen (PaO(2)) greater than 300 on 100% fraction of inspired oxygen, smoking, absence of aspiration/sepsis, and purulent secretions. Multivariable survival methods were used to determine relevance of these and new variables, adjusted for recipient risk factors., Results: In 56% of transplants, variance from at least one guideline was observed: chest radiograph, 41%; smoking, 21%; and PaO(2), 18%; but rarely ABO compatibility (0.06%). Practice within guidelines was not associated with increased mortality. Common variances from guidelines; eg, PaO(2)/fraction of inspired oxygen down to 230, were not associated with increased mortality, but smoking (p = 0.02) was. New donor variables associated with increased mortality were diabetes (p = 0.001), presence of cytomegalovirus antibodies (p < 0.0001), recent smoking history (p = 0.02), African-American (p = 0.005), blood type A (p = 0.02), death other than from head trauma (p = 0.02), and gender (p = 0.02), race (p = 0.03), and size (p = 0.002) discordances., Conclusions: Variance from current donor guidelines for lung transplantation is frequent; analysis suggests that donor PaO(2) ranges can be widened and a suspicious chest radiograph, evidence of sepsis, and purulent bronchial secretions ignored. Older age and smoking history appear to have a minor impact. New and possibly important factors identified suggest the need to better understand the impact of a wider range of donor variables on recipient outcomes., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The David reimplantation procedure is the preferred method of preserving tricuspid aortic valves during aortic root replacement. We report the results of a simplified approach to the David valve-sparing root reimplantation., Methods: Of 234 patients who underwent David reimplantation or some modification thereof, 129 operated on from January 2001 to June 2008 formed a consecutive single-surgeon series for midterm evaluation. Aortic anulus-left ventricular outflow tract and proximal tube graft size were reduced over a Hegar dilator to mean normal diameter based on body surface area, in the process creating neo-sinuses to accommodate cusp opening. Sixty-one patients (47%) had Marfan syndrome. Mean body surface area was 2.1 +/- 0.27 m(2). Preoperative aortic regurgitation grade was 1+ or less in 46%, 2+ in 26%, 3+ in 24%, and 4+ in 4.3%., Results: Left ventricular outflow tract sizing by Hegar dilator was 17 mm in 9.5% of patients, 19 mm in 18%, 21 mm in 56%, and 23 mm in 16%. Fifty-five (43%) had concomitant cusp repair. Postoperative aortic regurgitation grade was 0 in 98%, and none of the remaining had greater than 2+ AR. Postoperative mean aortic gradient was 9.0 +/- 3.5 mm Hg. No patient had intraoperative abandonment of the repair, and there were no postoperative deaths or strokes. Five-year survival was 99%, and 4 patients (3%) required late valve replacement., Conclusions: A simple modification of the David operation, reducing anular size, and creating neo-sinuses preserves the aortic valve, eliminates aortic regurgitation, avoids aortic stenosis, and has favorable midterm results., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The study objectives were to (1) compare survival after lung transplantation in patients requiring pretransplant mechanical ventilation or extracorporeal membrane oxygenation with that of patients not requiring mechanical support and (2) identify risk factors for mortality., Methods: Data were obtained from the United Network for Organ Sharing for lung transplantation from October 1987 to January 2008. A total of 15,934 primary transplants were performed: 586 in patients on mechanical ventilation and 51 in patients on extracorporeal membrane oxygenation. Differences between nonsupport patients and those on mechanical ventilation or extracorporeal membrane oxygenation support were expressed as 2 propensity scores for use in comparing risk-adjusted survival., Results: Unadjusted survival at 1, 6, 12, and 24 months was 83%, 67%, 62%, and 57% for mechanical ventilation, respectively; 72%, 53%, 50%, and 45% for extracorporeal membrane oxygenation, respectively; and 93%, 85%, 79%, and 70% for unsupported patients, respectively (P < .0001). Recipients on mechanical ventilation were younger, had lower forced vital capacity, and had diagnoses other than emphysema. Recipients on extracorporeal membrane oxygenation were also younger, had higher body mass index, and had diagnoses other than cystic fibrosis/bronchiectasis. Once these variables, transplant year, and propensity for mechanical support were accounted for, survival remained worse after lung transplantation for patients on mechanical ventilation and extracorporeal membrane oxygenation., Conclusion: Although survival after lung transplantation is markedly worse when preoperative mechanical support is necessary, it is not dismal. Thus, additional risk factors for mortality should be considered when selecting patients for lung transplantation to maximize survival. Reduced survival for this high-risk population raises the important issue of balancing maximal individual patient survival against benefit to the maximum number of patients., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: The surgical approach to ischemic cardiomyopathy maximizing survival remains a dilemma, with decisions complicated by secondary mitral regurgitation, ventricular remodeling, and heart failure. As a component of decision support, we sought to develop prediction models for comparing survival after coronary artery bypass grafting alone, coronary artery bypass grafting plus mitral valve anuloplasty, coronary artery bypass grafting plus surgical ventricular restoration, and listing for cardiac transplantation., Methods: From 1997 to 2007, 1468 patients with ischemic cardiomyopathy (ejection fraction <30%) underwent coronary artery bypass grafting alone (n = 386), coronary artery bypass grafting plus mitral valve anuloplasty (n = 212), coronary artery bypass grafting plus surgical ventricular restoration (n = 360), or listing for cardiac transplantation (n = 510). Mean follow-up was 3.8 +/- 2.8 years, with 5577 patient-years of data available for analysis. Risk factors were identified for early and late mortality by using 80% training and 20% validation sets. Outcomes were calculated for each applicable strategy to identify which maximized predicted 5-year survival. Models were programmed as a strategic decision-support tool., Results: One-, 5-, and 9-year survival were as follows, respectively: coronary artery bypass grafting, 92%, 72%, and 53%; coronary artery bypass grafting plus mitral valve anuloplasty, 88%, 57%, and 34%; coronary artery bypass grafting plus surgical ventricular restoration, 94%, 76%, and 55%; and listing for cardiac transplantation, 79%, 66%, and 54%. Risk factors included older age, higher New York Heart Association class, lower ejection fraction, longer interval from myocardial infarction to operation, and numerous comorbidities. Predicted and observed survivals in validation groups were similar (P > .1). Patient-specific simultaneous solutions of applicable models revealed therapy potentially providing maximum survival benefit. Coronary artery bypass grafting alone and listing for cardiac transplantation often maximized 5-year survival; only 15% of patients undergoing coronary artery bypass grafting plus mitral valve anuloplasty were predicted to fare best with this therapy., Conclusion: Validated prediction models can aid surgeons in recommending personalized treatment plans that maximize short- and long-term survival for ischemic cardiomyopathy., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Smoking cessation is presumed to be beneficial before resection of lung cancer. The effect of smoking cessation on outcome was investigated., Methods: From January 1999 to July 2007, in-hospital outcomes for 7990 primary resections for lung cancer in adults were reported to the Society of Thoracic Surgeons General Thoracic Surgery Database. Risk of hospital death and respiratory complications was assessed according to timing of smoking cessation, adjusted for clinical confounders., Results: Hospital mortality was 1.4% (n = 109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 (p = 0.03), 4.6 (p = 0.03), 2.6 (p = 0.7), and 2.5 (p = 0.11) for those whose timing of smoking cessation was categorized as current smoker, quit from 14 days to 1 month, 1 to 12 months, or more than 12 months preoperatively, respectively. Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but 6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27 of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 (p = 0.03), 1.62 (p = 0.14), 1.51 (p = 0.20), and 1.29 (p = 0.3) for those whose timing of smoking cessation was categorized as above., Conclusions: Risks of hospital death and pulmonary complications after lung cancer resection were increased by smoking and mitigated slowly by preoperative cessation. No optimal interval of smoking cessation was identifiable. Patients should be counseled to stop smoking irrespective of surgical timing.

Background: Because emerging percutaneous mitral valve repair may address only leaflets and not the anulus, we compared durability of mitral valve repair with and without prosthetic anuloplasty., Methods: From 1985 to 2007, 3,057 patients underwent primary isolated posterior leaflet repair for degenerative mitral disease either with prosthetic anuloplasty (n = 2,754, 90%) or without (n = 303, 9.9%: no anuloplasty, 68; suture anuloplasty, 7; pericardial anuloplasty, 228). Most of the latter operations occurred in the early 1990s. Differences in patient characteristics were addressed by propensity-score adjustment and matching (214 pairs). In all, 3,870 echocardiograms for 1,236 patients were available for assessing mitral regurgitation after prosthetic anuloplasty and 257 in 99 patients without one. Mean follow-up for mitral valve reoperation was 4.2 +/- 4.1 years, with 13,003 patient-years of data available for analysis., Results: Early, and to a lesser degree late, postoperative mitral regurgitation was less after prosthetic anuloplasty than repair without one, and this difference persisted after risk adjustment and in propensity-matched patients (p = 0.0002). Freedom from mitral valve reoperation was 96% and 94% at 10 years after repair with versus without prosthetic anuloplasty in unmatched groups, and 97% and 96% in matched groups (p = 0.3), respectively. Unadjusted survival was greater with than without prosthetic anuloplasty (84% versus 81% at 10 years, p = 0.009), but similar after propensity adjustment and in matched pairs., Conclusions: Mitral valve repair without a prosthetic anuloplasty was associated with accelerated return of mitral regurgitation, although risk-adjusted survival was similar. This finding has important implications for durability of percutaneous mitral repair techniques that do not address both leaflets and anulus.

Background: Blood transfusion has been shown to impact rejection after renal and cardiac transplantation, but it has not been studied after lung transplantation (LTx). In this study we assess: (1) patterns of transfusion, and (2) temporal interrelationships with histologic evidence of rejection., Methods: From July 1998 to January 2006, 326 of 331 patients undergoing LTx had available for study both time-related post-operative blood transfusion data and their series of transbronchial biopsy evaluations of perivascular rejection grade (Grades A0 to A4). Longitudinal temporal decomposition for ordinal variables was used to characterize prevalence of rejection grade and simultaneously assess the influence of (a) red blood cell (RBC), (b) platelet and (c) plasma administration., Results: Although peri-operative transfusion was common, transfusions continued at a low, steady rate throughout the life of LTx patients; patients received a total of 2,841 RBC units through follow-up. Immediately after LTx, the prevalence of Grade A0 rejection was 51%, and this increased to 84% by 6 months. RBC transfusion between biopsies was associated with lower histologic grade of rejection (70%, 73% and 77% with Grade A0 for 0, 1 and 12 units, respectively; p = 0.009), and this was particularly evident early after LTx. Histologic grade was not influenced by platelets or plasma., Conclusions: Transfusion requirements are high and continue throughout life after LTx; causes and effective treatment of persistent anemia should be sought. RBC transfusion appears to have an immunosuppressive effect, particularly early after transplant.

Objectives: To relate cardiovascular magnetic resonance-derived segmental wall motion and myocardial scarring and determine whether they are associated with postoperative mitral regurgitation following coronary artery bypass grafting and annuloplasty for severe functional ischemic mitral regurgitation., Methods: From January 2001 to October 2006, 29 patients with grade >or=3+ chronic functional ischemic mitral regurgitation were studied using cardiovascular magnetic resonance. Wall motion abnormality was graded for 17 standard left ventricular myocardial segments (0 = none, 1+ = hypokinesis, 2+ = severe hypokinesis, 3+ = akinesis, 4+ = dyskinesis), as was degree of hyperenhancement (scarring). Postoperative mitral regurgitation was assessed longitudinally by 71 transthoracic echocardiograms., Results: Wall motion abnormalities grade >or=2+ were present in most myocardial segments (median 13). Scar >25% was present in a median of 3 segments, and 44% of those were in the territory of the posterior papillary muscle. Nearly all segments (95%) with >25% scar had >or=2+ wall motion abnormality. Although 90% of patients had no mitral regurgitation at hospital discharge, by 6 months, 34% had mitral regurgitation grade >or=2+. There was little association between wall motion abnormality and recurrence of mitral regurgitation (P > .1). Seventy percent of patients with scar >25% in the posterior papillary muscle region exhibited postoperative mitral regurgitation of grade >or=2+ by 6 months, compared with 15% with score

Objective: The impact of size matching between donor and recipient is unclear in lung transplantation. Therefore, we determined the relation of donor lung size to 1) posttransplant survival and 2) pulmonary function as measured by forced expiratory volume in 1 second., Methods: From 1990 to 2006, 469 adults underwent lung transplantation with lungs from donors aged 7 to 70 years. Donor and recipient total lung capacities were calculated using established formulae (predicted total lung capacity), and actual recipient lung size was measured in the pulmonary function laboratory. Disparity between donor and recipient lung size was expressed as a ratio of donor predicted total lung capacity to recipient predicted total lung capacity-the predicted total lung capacity ratio-and predicted donor total lung capacity to actual recipient total lung capacity-the actual total lung capacity ratio. Survival was measured by multiphase hazard methodology and repeated measures of National Health and Nutrition Examination Survey-normalized forced expiratory volume in 1 second analyzed by temporal decomposition., Results: Predicted total lung capacity ratio and actual total lung capacity ratio ranged widely, from 0.55 to 1.59 and 0.52 to 4.20, respectively. Overall survival was unaffected by predicted total lung capacity ratio (P = .3) or actual total lung capacity ratio (P = .5). Patients with emphysema and an actual total lung capacity ratio of 0.67 or less or 1.03 or greater had higher predicted mortality (P = .01). During the first posttransplant year, forced expiratory volume in 1 second increased and then gradually declined. Predicted total lung capacity ratio and actual total lung capacity ratio had a small impact on forced expiratory volume in 1 second, primarily in the late phase after transplant in a disease-specific manner., Conclusion: Size matching between donor and recipient using predicted total lung capacity ratio and actual total lung capacity ratio is an effective technique. Wide discrepancies in lung sizing do not affect overall posttransplant survival or pulmonary function. Therefore, a greater degree of lung size mismatch can likely be accepted, thereby improving patients' odds of undergoing transplantation.

Background: It is unknown whether coronary reintervention confers a survival advantage when a previously placed left internal thoracic artery graft to the left anterior descending coronary artery (LAD) is patent. We compared survival after medical therapy, percutaneous intervention, and reoperative coronary artery bypass grafting in such patients who developed non-LAD territory jeopardy., Methods: From 1971 to 2000, 4,640 patients with prior coronary artery bypass grafting that included left internal thoracic artery to LAD grafting were found on angiography during active follow-up to have a patent left internal thoracic artery to LAD graft, but at least 50% stenosis of non-LAD territories or grafts to them. Two survival analyses were performed: (1) intent-to-treat, which included patients undergoing reoperative coronary artery bypass grafting (n = 731) or percutaneous intervention (n = 994) within 6 weeks of angiography or medical management (n = 2,782), and (2) competing risk/crossover, in which patients were classified as medically managed until crossover to coronary artery bypass grafting or percutaneous intervention., Results: In the intent-to-treat analysis, propensity-adjusted early (<1 year) survival was similar for all patients, but late survival was slightly better after percutaneous intervention than with medical management (p < or = 0.05). In the competing risk/crossover analysis, adjusted survival was best for medically treated patients early; however, late survival was similar among all three groups., Conclusions: Patients with patent left internal thoracic artery to LAD grafts who develop non-LAD territory jeopardy derive no survival benefit from reintervention, consistent with previous observations that for coronary reintervention to improve survival, the LAD territory must be jeopardized. Reintervention in patients with a patent left internal thoracic artery to LAD graft may be warranted to relieve symptoms, without expecting a survival benefit.

Objectives: Right ventricular sinus myectomy has been proposed for pulmonary atresia with intact ventricular septum for morphology falling within the uncertain area for eventual biventricular repair. Our objective was to evaluate right ventricular sinus myectomy by characterizing the morphologic spectrum of these patients, determining whether biventricular repair was achieved, ascertaining growth of right-sided structures, and assessing survival., Methods: We evaluated medical records, all imaging studies, and follow-up data (complete in all but 1 patient) from 43 patients with pulmonary atresia with intact ventricular septum treated from October 1993 to July 2005, 16 of whom underwent right ventricular sinus myectomy. Serial echocardiographic measurements of right-sided cardiac structures were converted to Z values to estimate their growth relative to somatic growth., Results: Patients undergoing right ventricular sinus myectomy had mild-to-moderate right ventricular size diminution (grade -1.2 +/- 3.2) and a tricuspid valve Z value of -4.9 +/- 1.9. Thirteen (87%) of the 16 patients achieved biventricular repair. After right ventricular sinus myectomy, mean right ventricular cavity size grade increased to 1.4 +/- 0.66, but the tricuspid valve Z value did not change appreciably over time. Five-year survival after sinus myectomy was 85%; late deaths were in patients with the smallest tricuspid valves at presentation (Z value < -7)., Conclusions: Right ventricular sinus myectomy in the uncertain area for biventricular repair of pulmonary atresia with intact ventricular septum leads to immediate increase in right ventricular volume. It, in combination with establishing right ventricle-pulmonary trunk continuity, allowed early biventricular repair in 87% of patients. However, tricuspid valve growth in relation to somatic growth was minimal. Thus, small tricuspid valve size might limit the long-term success of biventricular repair achieved by means of right ventricular sinus myectomy.

Background: Aortic valve allograft reoperation is a challenge for the surgeon and a risk to the patient. We examined our experience to identify these challenges and risks., Methods: From April 1987 to January 2006, 130 patients underwent first-time allograft-related reoperations. Prior implant was subcoronary 32 (25%), inclusion-root 28 (22%), and root 70 (53%). Reoperative indications were technical failure 11 (8.4%), endocarditis 31 (24%), and structural valve deterioration 88 (68%). Reoperative technique was allograft repair 7 (5.4%), simple valve replacement 80 (62%), and root replacement 43 (33%). Median follow-up was 3.1 years., Results: Surgical challenges: 10 adverse intraoperative events occurred (7.7%), 3 allograft specific, with rescue from all. Reoperative procedure was highly dependent on original implantation technique (31 of 43 root replacements after previous roots) and reoperative indication (24 of 43 root replacements for endocarditis). Implanted valve prostheses were small for patient size, less so in intact native roots (previous subcoronary or inclusion root) than retained allografts (Z-value, -1.1 versus -1.6; p = 0.08), but allograft root re-replacement allowed normal-sized valves. Patient risks: Relevant postoperative morbidities included reoperation for bleeding 7 (5.4%), new pacemaker 6 (5.2%), stroke 1 (0.8%), and no myocardial infarction. Hospital mortality was 3.8% (5 of 130), 6.5% (2 of 31) for endocarditis. Late patient survival was substantially worse for endocarditis than for structural valve deterioration (60% versus 90% at 5 years, p = 0.0006). Five-year freedom from further reoperation was 94%., Conclusions: Surgical challenges, even with endocarditis, can be surmounted and patient risks minimized by thoughtful preparation and appropriate reoperative procedure. An intact native root maximizes surgical options.

Objectives: The goal of this study was to assess the concordance between the American College of Cardiology (ACC) and the American Heart Association (AHA) 2004 Guideline Update for Coronary Artery Bypass Graft Surgery and actual clinical practice., Background: There is substantial geographic variability in the population-based rates of coronary artery bypass graft (CABG) procedures, and in recent years, there have been several public concerns about unnecessary cardiac care. The actual rate of inappropriate cardiac procedures is unknown., Methods: We evaluated 4,684 consecutive isolated coronary artery bypass graft procedures performed in 2004 and 2005 in northern New England. Our regional registry data were used to categorize patients into clinical subgroups. Detailed clinical criteria were then used to categorize procedures within these subgroups as class I (useful and effective), class IIa (evidence favors usefulness), class IIb (evidence less well established), and class III (not useful or effective)., Results: Among these 4,684 procedures, we were able to classify 99.6% (n = 4,665). The majority of procedures were class I (87.7%). Class II procedures totaled 10.9%. The remaining 1.4% of procedures were class III., Conclusions: In this regional study, we found that 98.6% of CABG procedures that could be classified were considered to be appropriate. In these data, actual clinical practice closely follows the recommendations of the 2004 ACC/AHA guidelines for CABG surgery.

Objective: Recommendations for aortic valve replacement in severe aortic stenosis are based primarily on the presence of symptoms. However, the onset of symptoms is often insidious, potentially leading to delayed intervention and suboptimal results. Identifying factors that reduce the survival of patients undergoing aortic valve replacement could lead to revised treatment guidelines and improved outcomes., Methods: We conducted a single-center observational clinical study of 3049 patients with aortic stenosis who underwent native aortic valve replacement with a single type of bioprosthesis. The primary end point was all-cause mortality from the date of operation. Multivariable analysis of risk factors for death was performed in the multiphase hazard function domain., Results: The presence of severe left ventricular hypertrophy at operation, which preceded symptoms in 17% of patients, was associated with decreased survival. This effect was magnified by the severity of aortic stenosis (P = .02) and use of small prostheses (P = .01). The presence of left ventricular dysfunction reduced survival (P = .0003). Although older age was a risk factor for death (P < .0001), elderly patients had survival comparable to their age, race, and sex-matched cohorts, whereas younger patients had worse than expected survival that was further diminished with insertion of a small prosthesis (P = .01)., Conclusion: To optimize survival, earlier aortic valve replacement should be considered even in asymptomatic patients before severe left ventricular hypertrophy or dysfunction develops. In younger patients, the largest possible prosthesis should be implanted to minimize residual gradient; in elderly patients, complex operations just to insert larger prostheses should be avoided.

Objectives: To address the present controversy regarding optimal management of status 2 heart transplant candidates, we studied the short- and long-term fate of medically improved patients removed from our transplant waiting list to assess return of heart failure and occurrence of sudden cardiac death, identify interventions to improve outcomes, and compare their survival with that of similar transplanted patients., Methods: From January 1985 to February 2004, 100 status 2 patients were delisted for medical improvement (median on-list duration, 314 days). Return of heart failure, sudden cardiac death, and all-cause mortality were determined from follow-up (mean, 7.7 +/- 3.9 years among survivors; 10% followed >12 years). Hazard function modeling, competing-risks analyses, simulation, and propensity matching to equivalent patients undergoing transplantation were used to analyze and compare outcomes and predict benefit of interventions., Results: Freedom from return of heart failure was 77% at 5 years. The most common mode of death was sudden cardiac death, with risk peaking at 2.5 years after delisting but remaining at 3.5% per year thereafter. Event-free survival at 1, 5, and 10 years was 94%, 55%, and 28%, respectively; simulation demonstrated that implantable cardioverter-defibrillators could have improved this to 45% at 10 years. Overall survival after delisting was better than that of matched status 2 patients who underwent transplantation, but was demonstrably worse after 30 months., Conclusions: Status 2 patients, including those delisted, require vigilant surveillance and optimal medical management, implantable cardioverter-defibrillators, and a revised approach to transplantation timing, such that overall salvage is maximized while allocation of scarce organs is optimized.

Objective: The study objective was to identify characteristics differentiating patients undergoing valve replacement versus valve repair for degenerative mitral valve disease and to use this information to compare survival and reoperation after each procedure., Methods: From 1985 to 2005, 3286 patients underwent isolated primary operation for degenerative mitral valve disease. Valve repair was performed in 3051 patients (93%), and valve replacement was performed in 235 patients (7.2%). A propensity model and score developed for fair comparison of outcomes yielded 195 matched pairs., Results: Patients undergoing replacement were older (70 +/- 12 years vs 57 +/- 13 years) and had more complex valvar pathology, symptoms, and left ventricular dysfunction. Thus, the characteristics of the propensity-matched patients undergoing repair more resembled those of the patients undergoing replacement (older, complex valvar pathology) than patients undergoing typical repair. Eight patients died in the hospital (0.26%) after repair and 5 patients (2.1%) died after replacement (P = .001). Unadjusted survival at 5, 10, and 15 years was 95%, 87%, and 68% after repair and 80%, 60%, and 44% after replacement, respectively (P < .0001); however, among propensity-matched patients, survival was similar (P = .8): 86% versus 83% at 5 years, 63% versus 62% at 10 years, and 43% versus 48% at 15 years. Freedom from reoperation among propensity-matched patients was 94% at 5 and 10 years after repair and 95% and 92% at 5 and 10 years after replacement, respectively (P = .6)., Conclusion: It is reasonable to perform valve repair in elderly patients with complex degenerative mitral valve pathology because it can eliminate the need for anticoagulation and risk of prosthesis-related complications. However, when valve pathology is so complex that repair is infeasible, this study demonstrates that valve replacement does not diminish long-term outcomes.

Background: Predicting risk for aortic and mitral valve surgery is important both for informed consent of patients and objective review of surgical outcomes. Development of reliable prediction rules requires large data sets with appropriate risk factors that are available before surgery., Methods: Data from eight Northern New England Medical Centers in the period January 1991 through December 2001 were analyzed on 8943 heart valve surgery patients aged 30 years and older. There were 5793 cases of aortic valve replacement and 3150 cases of mitral valve surgery (repair or replacement). Logistic regression was used to examine the relationship between risk factors and in-hospital mortality., Results: In the multivariable analysis, 11 variables in the aortic model (older age, lower body surface area, prior cardiac operation, elevated creatinine, prior stroke, New York Heart Association [NYHA] class IV, congestive heart failure [CHF], atrial fibrillation, acuity, year of surgery, and concomitant coronary artery bypass grafting) and 10 variables in the mitral model (female sex, older age, diabetes, coronary artery disease, prior cerebrovascular accident, elevated creatinine, NYHA class IV, CHF, acuity, and valve replacement) remained independent predictors of the outcome. The mathematical models were highly significant predictors of the outcome, in-hospital mortality, and the results are in general agreement with those of others. The area under the receiver operating characteristic curve for the aortic model was 0.75 (95% confidence interval [CI], 0.72 to 0.77), and for the mitral model, 0.79 (95% CI, 0.76 to 0.81). The goodness-of-fit statistic for the aortic model was chi(2) [8 df] = 11.88, p = 0.157, and for the mitral model it was chi(2) [8 df] = 5.45, p = 0.708., Conclusions: We present results and methods for use in day-to-day practice to calculate patient-specific in-hospital mortality after aortic and mitral valve surgery, by the logistic equation for each model or a simple scoring system with a look-up table for mortality rate.

Background: The etiology of mitral valvular disease has changed in the last 20 years, and new techniques for the diagnosis and repair of mitral valves have been advanced. A retrospective regional study was conducted to identify changes in patient and disease characteristics and in population-based rates for mitral valve repair and replacement in northern New England., Methods: Data from 1648 patients were collected from 5 clinical centers in Maine, New Hampshire, and Vermont between January 1, 1990, and December 31, 1999. U.S. Census data were used to calculate population-based rates., Results: Total mitral valve procedures increased 2.4 times, from 8.7 to 20.6 cases/100,000/year (p(trend) = 0.004). Primary procedures increased from 6.7 to 16.9 cases/100,000/year (p(trend) = 0.014). Primary mitral valve repair procedures increased 3.7 times, from 2.4 to 8.9 cases/100,000/year (p(trend) = 0.012), whereas mitral valve replacement increased only 1.9 times, from 4.3 to 8.0 cases/100,000/year (p(trend) = 0.016). Repeat mitral valve operations did not change significantly (p(trend) = 0.810). During this period, there was a significant increase of the percentage of octogenarians (p(trend) = 0.016) and of patients with ejection fractions <40% (p(trend) = 0.012). There was a decrease in the percentage of patients with mitral stenosis (p(trend) = 0.024)., Conclusion: In an era of a change in the etiology of mitral valvular disease and new techniques for diagnosis and repair of mitral valvular disease, regional data demonstrate substantial increased rates of mitral repair and replacement and expanded indications of older age and poorer left ventricular function.

Background: A prospective regional study was conducted to identify factors associated with in-hospital mortality among patients undergoing isolated coronary artery bypass graft surgery (CABG). A prediction rule was developed and validated based on the data collected., Methods and Results: Data from 3,055 patients were collected from five clinical centers between July 1, 1987, and April 15, 1989. Logistic regression analysis was used to predict the risk of in-hospital mortality. A prediction rule was developed on a training set of data and validated on an independent test set. The metric used to assess the performance of the prediction rule was the area under the relative operating characteristic (ROC) curve. Variables used to construct the regression model of in-hospital mortality included age, sex, body surface area, presence of comorbid disease, history of CABG, left ventricular end-diastolic pressure, ejection fraction score, and priority of surgery. The model significantly predicted the occurrence of in-hospital mortality. The area under the ROC curve obtained from the training set of data was 0.74 (perfect, 1.0). The prediction rule performed well when used on a test set of data (area, 0.76). The correlation between observed and expected numbers of deaths was 0.99., Conclusions: The prediction rule described in this report was developed using regional data, uses only eight variables, has good performance characteristics, and is easily available to clinicians with access to a microcomputer or programmable calculator. This validated multivariate prediction rule would be useful both to calculate the risk of mortality for an individual patient and to contrast observed and expected mortality rates for an institution or a particular clinician.

Objective: A prospective regional study was conducted to determine if the observed differences in in-hospital mortality rates associated with coronary artery bypass grafting (CABG) are solely the result of differences in patient case mix. DESIGN-Regional prospective cohort study. Data including patient demographic and historical data, body surface area, cardiac catheterization results, priority of surgery, comorbidity, and status at hospital discharge were collected. This study presents data for 3055 CABG patients between July 1, 1987, and April 15, 1989., Setting: This study includes data from all surgeons performing cardiothoracic surgery in Maine, New Hampshire, and Vermont; the data were collected from five regional medical centers., Patients: Data were collected from all consecutive isolated CABG surgery patients during the study period., Main Outcome Measures: Crude and adjusted in-hospital mortality rates associated with CABG., Main Results: The overall crude in-hospital mortality rate for isolated CABG was 4.3%. The rate varied among centers (range, 3.1% to 6.3%) and among surgeons (range, 1.9% to 9.2%). Predictors of in-hospital mortality included increased age, female gender, small body surface area, greater comorbidity, reoperation, poorer cardiac function as indicated by a lower ejection fraction, increased left ventricular end diastolic pressure and emergent or urgent surgery. After adjusting for the effects of potentially confounding variables, substantial and statistically significant variability was observed among medical centers (P = .021) and among surgeons (P = .025)., Conclusion: We conclude that the observed differences in in-hospital mortality rates among institutions and among surgeons in northern New England are not solely the result of differences in case mix as described by these variables and may reflect differences in currently unknown aspects of patient care. Understanding this variation requires a detailed understanding of the processes of care.

In the last 10 years, our center has managed 60 cases of aortic rupture from blunt chest trauma. Nineteen patients died (32%), 11 of whom were moribund on admission. Two patients out of ten who had undergone aortography at other institutions arrived at our hospital with massive bleeding in the left chest and died despite immediate operation. Six patients exsanguinated 1 to 2 1/2 hours after admission while aortography was being arranged or performed, and review of these cases to identify clinical signs of high risk revealed that left hemothorax, pseudocoarctation, and/or supraclavicular hematoma were present in five of the six. It appeared that the survival rate of patients suspected of blunt aortic trauma who had any of these clinical signs might be improved if they were taken directly to the operating room. To investigate this possibility we reviewed all cases from the past 10 years (excluding patients moribund on arrival or who had aortography elsewhere) in whom suspicion of aortic trauma led to aortography or surgery. Thirteen of the 17 patients (76%) with one or more signs of high risk had torn the aortic isthmus, compared to 26 of 154 patients (17%) without these signs. Five of the high-risk group (29%) exsanguinated, compared to one (less than 1%) of the others. No patient in this series died from unsuspected aortic trauma, which we attribute to the liberal use of aortography. Except for the patients with exsanguinating hemorrhage preoperatively, there were no operative or postoperative deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

The case histories of two infants with aortic thrombosis are presented. Clinically, an obstructive aortic arch lesion was suspected because of a systolic pressure gradient between the upper and lower extremities in one infant and unequal peripheral pulses with lower limb cyanosis in the other. Noninvasive studies were inconclusive, the only abnormality noted echocardiographically being severe left ventricular dysfunction. Cardiac catheterization including angiography defined the severity of the obstruction and location of the thrombus in both babies. The thrombus originated within a ductus arteriosus aneurysm in one infant and was located in the ascending aorta and transverse arch in the other. Although successful surgical removal was accomplished, both babies died unexpectedly in the early postoperative period.