Contemporary utilization of the axillary artery in cardiac surgery.

INTRODUCTION: The axillary artery is a reliable inflow vessel when addressing pathology of the aortic root and aortic arch that may preclude standard central cannulation strategies. This narrative review examines the use of the axillary artery in cardiac surgery. Anatomy, indications for use, cannulation strategies, and potential complications will be discussed. METHODS: A comprehensive review of the current literature was performed using PubMed, Cochrane Review, and authoritative committee guidelines. A narrative review incorporating current available evidence was undertaken. COMMENT: Use of the axillary artery in select cardiac surgical cases is reliable, reproducible, and may be preferable in certain cases involving ascending aortic pathology, reoperative surgery, porcelain aorta, access for transcatheter valve therapies, and peripheral mechanical circulatory support.

Aortic Prosthetic Valve Endocarditis: Analysis of The Society of Thoracic Surgeons Database.

BACKGROUND: This study sought to characterize the current US experience of aortic prosthetic valve endocarditis (PVE) compared with native valve endocarditis (NVE). METHODS: The Society of Thoracic Surgeons Database was queried for entries of active aortic infective endocarditis (IE). Two analyses were performed: (1) trends of surgical volume and operative mortality (2011-2019); and (2) descriptive and risk-adjusted comparisons between PVE and NVE (2014-2019) using multivariable logistic regression. RESULTS: From 2011 to 2019, there was a yearly increase in the proportion of PVE (20.9% to 25.9%; P < .001) with a concurrent decrease in operative mortality (PVE, 22.5% to 10.4%; P < .001; NVE, 10.9% to 8.5%; P < .001). From 2014 to 2019, active aortic IE was identified in 9768 patients (NVE, 6842; PVE, 2926). Aortic root abscess (50.1% vs 25.2%; P < .001), aortic root replacement (50.1% vs 12.8%; P < .001), homograft implantation (27.2% vs 4.1%; P < .001), and operative mortality (12.2% vs 6.4%; P < .001) were higher in PVE. After risk adjustment, PVE (odds ratio [OR], 1.5; 95% CI,1.16-1.94; P < .01), aortic root replacement (OR, 1.49; 95% CI,1.15-1.92; P < .001), Staphylococcus aureus (OR, 1.5; 95% CI,1.23-1.82; P < .001), and unplanned revascularization (OR, 5.83; 95% CI,4.12-8.23; P < .001) or mitral valve surgery (OR, 2.29; 95% CI,1.5-3.51; P < .001) correlated with a higher operative mortality, whereas prosthesis type (P = .68) was not an independent predictor. CONCLUSIONS: IE in the United States has risen over the past decade. However, operative mortality has decreased for both PVE and NVE. PVE, extension of IE requiring aortic root replacement, and additional unplanned surgical interventions carry an elevated mortality risk. Prosthesis selection did not affect operative mortality.

Risk Analysis and Outcomes of Postoperative Renal Failure After Aortic Valve Surgery in the United States.

BACKGROUND: Postoperative renal failure (RF) compromises early outcomes in cardiac surgery. In contrast, long-term survival and progression of RF after aortic valve replacement (AVR) with or without coronary artery bypass graft surgery (CABG) remain undefined. METHODS: From 2008 through 2015, records of AVR with or without CABG in The Society of Thoracic Surgeons database were linked to Medicare claims data. Postoperative RF was categorized as being with new dialysis (RF-D) or without new dialysis (RF no-D). Cox proportional hazards models were used to conduct a risk analysis and evaluate outcomes in this patient group. RESULTS: Of 164,727 patients undergoing AVR with or without CABG, 3.5% had postoperative RF, of whom 63.3% required dialysis. Operative mortality of postoperative RF was 39.2%, higher for dialysis than for no-dialysis patients (46.1% vs 26.1%, P < .0001). Both RF dialysis patients and no-dialysis patients had a higher early (less than 30-day) mortality risk (hazard ratio [HR] 11.29, P < .0001 and HR 8.03, P < .0001, respectively) compared with no postoperative RF. At a median follow-up of 2.7 years, RF-D and RF no-D remained relevant risk factors, however, with a lower magnitude of effect (HR 2.42, P < .0001, and HR 1.69, P < .0001, respectively). Preoperative glomerular filtration rate (GFR) less than 30 mL · min-1 · 1.73 m-2 had a lower early mortality risk (HR 0.48, P < .0001) but higher late mortality risk (HR 1.5, P < .0001) compared with GFR greater than 60. Predictors for long-term progression to RF-D included preoperative GFR less than 30 (HR 13, P < .0001), GFR 30 to 60 (HR 2.47, P = .006), and insulin-dependent diabetes mellitus (HR 1.96, P = .001). CONCLUSIONS: Postoperative RF after AVR with or without CABG was associated with higher early and late mortality, which further increased with a new requirement for dialysis. Once postoperative RF develops, preoperative renal dysfunction does not increase early mortality; however, it predicts late survival. Preoperative renal function is associated with progression of postoperative RF to dialysis.