Off-Pump Coronary Artery Bypass Grafting and Transaortic Transcatheter Aortic Valve Replacement.

We sought to demonstrate the effectiveness of off-pump coronary artery bypass grafting and transcatheter aortic valve replacement in two patients with porcelain aortas and lesions that could not be optimally treated with percutaneous coronary intervention. Patients with aortic stenosis and coronary artery disease who are too high-risk for conventional surgical aortic valve replacement and coronary artery bypass grafting due to comorbidities and porcelain aorta, and who do not have the appropriate anatomy for percutaneous coronary intervention should be considered for concomitant transcatheter aortic valve replacement and off-pump coronary artery bypass grafting. doi: 10.1111/jocs.12762 (J Card Surg 2016;31:435-438).

Utility of Established Risk Models to Predict Surgical Mortality in Acute Type-A Aortic Dissection.

OBJECTIVE: The objective of this study was to determine the predictive value of 2 established risk models for surgical mortality in a contemporary cohort of patients undergoing repair of acute type-A aortic dissection. DESIGN: Retrospective analysis. SETTING: Single tertiary care hospital. PARTICIPANTS: Seventy-nine consecutive patients undergoing emergent repair of acute type-A aortic dissection between 2008 and 2013. INTERVENTION: All patients underwent emergent repair of acute type-A aortic dissection. MEASUREMENTS AND MAIN RESULTS: The receiver operating characteristic curve was compared for each scoring system. Of the 79 patients undergoing emergent repair of acute type-A aortic dissection, 23 (29.1%) were above the age of 70. Seventeen (21.5%) patients presented with hypotension, 25 (31.6%) presented with limb ischemia, and 10 (12.7%) presented with evidence of visceral ischemia. Overall operative mortality was 16.5%. Increasing age was the only preoperative variable associated with increased operative mortality. The areas under the receiver operating characteristic curve for operative mortality was 0.62 and 0.66 for the scoring systems developed by Rampoldi et al and Centofanti et al, respectively. The area under the receiver operating characteristic curve for operative mortality for age was 0.67. The areas under the receiver operating characteristic curve for operative mortality between the 2 scoring systems and for age were not statistically different. CONCLUSIONS: Existing predictive risk models for acute type-A aortic dissection provide moderate discriminatory power for operative mortality. Age as a single variable may provide equivalent discriminatory power for operative mortality as the established risk models.

Transcatheter Aortic and Mitral Valve Implantation (TAMVI) in Native Rheumatic Valves.

A 68-year-old female with moderate to severe aortic stenosis and severe mitral stenosis, deemed too high risk for surgery (STS mortality risk = 12.3%) with a porcelain aorta, was successfully treated with a transcatheter aortic and mitral valve implantation (TAMVI) via a transapical approach. A 23 mm Sapien valve (Edwards Lifesciences, Irvine, CA, USA) was placed in the aortic position and a 29 mm inverted Sapien valve (Edwards Lifesciences) in the mitral position.

Myocardial Infarction Classification on Outcomes in Nonemergent Coronary Artery Bypass Grafting.

BACKGROUND: Although patients with ST elevation myocardial infarctions (STEMIs) are known to have worse outcomes than patients with non-ST elevation myocardial infarctions (NSTEMIs), such differences are not well described in the subset of patients undergoing coronary artery bypass grafting. The purpose of this study is to compare postoperative outcomes of patients undergoing nonemergent coronary artery bypass grafting within 1 week after an STEMI versus NSTEMI. METHODS: A retrospective study was performed on patients undergoing isolated coronary artery bypass grafting between 1 and 7 days from an MI from 2008 to 2012. Postoperative outcomes, including mortality and composite postoperative morbidity for patients with STEMI versus NSTEMI, were compared within each group. RESULTS: Of the 446 patients undergoing nonemergent isolated coronary artery bypass grafting between 1 and 7 days after an MI, 122 patients (27.3%) had an STEMI. The STEMI cohort was younger with less incidence of hypertension than the NSTEMI cohort. However, aside from having a lower incidence of congestive heart failure, STEMI patients had an overall poorer cardiac status than NSTEMI patients. No differences were found in mortality, rates of major complication, length of intensive care unit stay, and length of hospital stay between STEMI and NSTEMI patients. CONCLUSION: Despite differences in preoperative characteristics and pathophysiology of patients undergoing coronary artery bypass grafting between 1 and 7 days after NSTEMI versus STEMI, no difference was found in early surgical outcome. The classification of MI should therefore not influence surgical decision making in such patients.

Impact of Preoperative Prealbumin on Outcomes After Cardiac Surgery.

BACKGROUND: Preoperative malnutrition is increasingly prevalent in patients undergoing cardiac surgery. Although prealbumin is a widely used indicator of nutrition status, its use in the preoperative assessment of patients undergoing cardiac surgery is not well defined. The purpose of this study is to determine the impact of preoperative prealbumin levels on outcomes after cardiac surgery. MATERIALS AND METHODS: Data were prospectively gathered from February 2013 to July 2013 on 69 patients undergoing cardiac surgery. Prealbumin levels were obtained within 24 hours of surgery. Patients were divided into 2 groups based on a prealbumin cutoff value of 20 mg/dL. RESULTS: Of the 69 patients, 32 (46.4%) had a preoperative prealbumin ≤ 20 mg/dL. There was no correlation between prealbumin levels and body mass index (r = -0.13, P = .28). Likewise, there was no correlation between preoperative albumin and prealbumin levels (r = 0.09, P = .44). Nine of 32 (28.1%) patients with low preoperative prealbumin levels had postoperative infections compared with 2 of 37 (5.4%) patients with high prealbumin levels (P = .010). Patients with low prealbumin levels also had increased risk of postoperative intubation for > 12 hours (P = .010). CONCLUSIONS: Patients undergoing cardiac surgery with preoperative prealbumin levels of ≤ 20 mg/dL have an increased risk for postoperative infections and the need for longer mechanical ventilation. If feasible, nutrition optimization of such patients may be considered prior to cardiac surgery.

Propensity-matched analysis of the effect of preoperative intraaortic balloon pump in coronary artery bypass grafting after recent acute myocardial infarction on postoperative outcomes.

INTRODUCTION: There is substantial variability in the preoperative use of intraaortic balloon pumps (IABPs) in patients undergoing coronary artery bypass grafting post myocardial infarction. The objective of this study is to determine the effect of preoperative IABPs on postsurgical outcomes in this subset of patients. METHODS: From 2007 to 2012, 877 patients underwent isolated coronary artery bypass post myocardial infarction. Four hundred and six patients were propensity-score matched based on the likelihood of receiving a preoperative balloon pump. Total blood transfusion requirements, composite in-hospital morbidity and/or mortality end point, total hours in the intensive care unit, and length of hospital stay were compared between the two groups. RESULTS: No significant differences in demographics, preoperative risk factors, intraoperative variables or length of hospital stay were found between patients with and without balloon pumps after propensity score matching. Compared to patients without balloon pumps, a higher percentage of patients with preoperative IABPs required transfusions. Patients with preoperative balloon pumps were more likely to have the composite end point of in-hospital morbidity (24.1% versus 12.8%, P <0.004), and increased hours in the intensive care unit (median hours: 69.0 versus 46.0, P <0.013) as compared to patients without balloon pumps. CONCLUSIONS: The use of preoperative IABPs in patients undergoing isolated coronary artery bypass grafting after myocardial infarction is associated with increased transfusion requirements, increased in-hospital morbidity and longer postoperative intensive care unit stay as compared to patients without IABPs.

Dose-dependent effects of intraoperative low volume red blood cell transfusions on postoperative outcomes in cardiac surgery patients.

OBJECTIVE: To determine the incremental risk associated with each intraoperative red blood cell transfusion in cardiac surgery patients. DESIGN: Retrospective analysis on prospectively collected data. SETTING: Single tertiary care hospital. PARTICIPANTS: Seven hundred forty-five patients undergoing on-pump cardiac surgery between January 2010 and June 2012 who received between 1 and 3 units of red blood cell transfusion intraoperatively. INTERVENTIONS: All patients received between 1 and 3 units of red blood cell transfusions. All transfusions were with leukoreduced blood that had been stored for < 14 days. MEASUREMENTS AND MAIN RESULTS: Postoperative complications and length of intubation were associated with the number of red blood cell units transfused. Transfusion of each additional unit of red blood cells was associated with incrementally worse outcomes. Median length of intubation was 11 hours, 12 hours, and 13 hours in patients receiving 1, 2, and 3 units of red blood cell transfusions, respectively (p < 0.005). Similarly, each additional unit of red blood cell transfusion was associated with increasing postoperative septicemia (0% v 0.35% v 2.29%, p < 0.006) and postoperative pneumonia (0% v 0.70% v 2.29%, p < 0.013). CONCLUSIONS: There is a step-wise increase in length of postoperative intubation with each red blood cell transfusion in patients undergoing cardiac surgery. Each additional unit of intraoperative RBC transfusion also may increase postoperative infectious complications. Thus, even single-unit reductions in red blood cell transfusions may have significant impact on outcomes.

P2Y12 platelet function assay for assessment of bleeding risk in coronary artery bypass grafting.

BACKGROUND: The use of platelet function testing has been advocated to individualize the time needed between discontinuation of P2Y12 inhibitors and coronary artery bypass grafting (CABG). However, the use of specific point-of-care assays to predict bleeding risk in patients on P2Y12 inhibitors prior to CABG has not been fully validated. METHODS: From September 2012 to May 2013, 81 patients on P2Y12 inhibitors underwent isolated CABG. Preoperative level of P2Y12 receptor blockade was measured using the VerifyNow P2Y12 assay. Packed red blood cell (pRBC) and platelet transfusions and postoperative chest tube output were correlated with preoperative P2Y12 reaction units (PRUs). RESULTS: Patients who stopped P2Y12 inhibitors for ≤3 days received significantly more platelet transfusions as compared to those whose inhibitors were stopped for longer (0.71 ± 1.05 units vs. 0.20 ± 0.71 units, p = 0.01). They also had increased postoperative chest tube output (552.5 ± 325.5 mL vs. 399.8 ± 146.5 mL, p = 0.03). There was no significant difference in platelet transfusions and chest tube output between patients whose preoperative PRU value was <250 compared to those whose values were ≥250. pRBC requirements were correlated with preoperative hematocrit and age but not with timing of discontinuation of P2Y12 inhibitors or with PRU levels. CONCLUSIONS: In patients on P2Y12 inhibitors undergoing CABG surgery, discontinuation of P2Y12 inhibitors three days prior to surgery rather than VerifyNow PRU values predicts postoperative bleeding and the need for platelet transfusions. Sole reliance on platelet function testing to determine the timing of surgery for patients on P2Y12 inhibitors should therefore be done with caution.

Regional changes in coaptation geometry after reduction annuloplasty for functional mitral regurgitation.

BACKGROUND: While it is known that band annuloplasty for functional mitral regurgitation (FMR) improves leaflet coaptation, the effect on regional coaptation geometry has not previously been well defined. We used three-dimensional transesophageal echocardiography (3D-TEE) to analyze the regional effects of semirigid band annuloplasty on annular geometry and leaflet coaptation zones of patients with FMR. METHODS: Sixteen patients with severe FMR underwent a semirigid band annuloplasty. Intraoperative full volume 3D-TEE datasets were acquired pre valve and post valve repair. Offline analysis assessed annular dimensions and regional coaptation zone geometry. The regions were defined as R1 (A1-P1), R2 (A2-P2), and R3 (A3-P3); coaptation distance, coaptation depth, and coaptation length were measured in each region. Differences were analyzed with repeated measures within a general linear model. RESULTS: Band annuloplasty decreased mitral regurgitation grade from 3.7 to 0.1 (scale 0 to 4). Annular septolateral dimension (p<0.01) and coaptation distance (p<0.01) decreased significantly in all regions. Likewise, anterior and posterior leaflet coaptation lengths increased in all regions (p<0.01 and p=0.05, respectively), with region 2 showing the greatest increase (p=0.01). Changes in coaptation depth were not significant. CONCLUSIONS: Semirigid band annuloplasty for FMR produces significant regional remodeling of leaflet coaptation zones, with region 2 showing the greatest increase in leaflet coaptation length. This regional analysis of annular geometry and leaflet coaptation creates a framework to better understand the mechanisms of surgical success or failure of annuloplasty for FMR.

Evolution of operative techniques and perfusion strategies for minimally invasive mitral valve repair.

OBJECTIVE: Perfusion strategies and operative techniques for minimally invasive mitral valve repair have evolved over time. During the past decade, our institution's approach has progressed from a port access platform with femoral perfusion to predominantly a central aortic cannulation through a right anterior minithoracotomy incision. We analyzed this institutional experience to evaluate the impact of approach on patient outcomes. METHODS: Between 1995 and 2007, 1282 patients (mean age, 59.3 years; range, 18-99 years) underwent first-time, isolated mitral valve repair using a minimally invasive technique. Patient demographics included peripheral vascular disease (3.2%), chronic obstructive pulmonary disease (8.3%), atherosclerotic aorta (6.5%), cerebrovascular disease (4.3%), and ejection fraction less than 30% (4.3%). Retrograde perfusion was performed in 394 (30.7%) of all patients and endoaortic balloon occlusion in 373 (29.1%); the operative technique was a right anterior minithoracotomy in 1264 (98.6%) and left posterior minithoracotomy in 18 (1.4%). The etiology of mitral disease was degenerative in 73.2%, functional in 20.6%, and rheumatic in 2.4%. Data were collected prospectively using the New York State Cardiac Surgery Report System and a customized minimally invasive surgery data form. Logistic analysis was used to evaluate risk factors and outcomes; operative experience was divided into tertiles. RESULTS: Overall hospital mortality was 2.0% (25/1282). Mortality was 1.1% (10/939) for patients with degenerative etiology and 0.4% (3/693) for patients younger than 70 years of age with degenerative valve disease. Risk factors for death were advanced age (P = .007), functional etiology (P = .010; odds ratio [OR] = 3.3), chronic obstructive pulmonary disease (P = .013; OR = 3.4), peripheral vascular disease (P = .014; OR = 4.2), and atherosclerotic aorta (P = .03; OR = 2.8). Logistic risk factors for neurologic events were advanced age (P = .02), retrograde perfusion (P = .001; OR = 3.8), and emergency procedure (P = .01; OR = 66.6). Interaction modeling revealed that the only significant risk factor for neurologic event was the use of retrograde perfusion in high-risk patients with aortic disease (P = .04; OR = 8.5). Analysis of successive tertiles during this 12-year experience revealed a significant decrease in the use of retrograde arterial perfusion (89.6%, 10.4%, and 0.0%; P < .001) and endoaortic balloon occlusion (89.3%, 10.7%, and 0%; P < .001). The overall frequency of postoperative neurologic events was 2.3% (30/1282) and decreased from 4.7% in the first tertile to 1.2% in the second and third tertiles (P < .001). CONCLUSIONS: Central aortic cannulation through a right anterior minithoracotomy for mitral valve repair allows excellent outcomes in patients with a broad spectrum of comorbidities and has become our preferred approach for most patients undergoing mitral valve repair. Retrograde arterial perfusion is associated with an increased risk of stroke in patients with severe peripheral vascular disease and should be reserved for select patients without significant atherosclerosis.

Minimally invasive valve surgery with antegrade perfusion strategy is not associated with increased neurologic complications.

BACKGROUND: A Society of Thoracic Surgeons' publication recently associated "minimally invasive" approaches with increased neurologic complications; this proposed association was questionable due to imprecise definitions. To critically reevaluate this issue, we reviewed a large minimally invasive valve experience with robust definitions. METHODS: From November 1995 to January 2007, 3,180 isolated, non-reoperative valve operations were performed; 1,452 (45.7%) were aortic replacements and 1,728 (54.3%) were mitral valve procedures. Surgical approach was standard sternotomy (28%) or minimally invasive technique (72%). Antegrade arterial perfusion was used in 2,646 (83.2%) patients and retrograde perfusion in 534 (16.8%). Aortic clamping was direct in 83.4%, with endoclamp in 16.4% and no clamp in 0.2%. Patients were prospectively followed in a proprietary database and the New York State Cardiac Surgery Reporting System (mandatory, government audited). A neurologic event was defined as a permanent deficit, a transient deficit greater than 24 hours, or a new lesion on cerebral imaging. RESULTS: Hospital mortality for aortic valve replacement was 4.0% (sternotomy [5.1%] versus minimally invasive [3.4%] p = 0.13); for mitral procedures it was 2.4% (sternotomy [4.8%] versus minimally invasive [1.8%] p = 0.001). Multivariate analysis revealed that age, female gender, renal disease, ejection fraction less than 0.30, chronic obstructive pulmonary disease, and emergent operation were risk factors for mortality. Stroke occurred in 71 patients (2.2%) (sternotomy [2.1%] versus minimally invasive [2.3%] p = 0.82). Multivariate analysis of neurologic events revealed that cerebrovascular disease, emergency procedure, no-clamp, and retrograde perfusion were risk factors. In patients 50 years old or younger (n = 662), retrograde perfusion had no significant impact on neurologic events (1.6% vs 1.1%, p = 0.57). CONCLUSIONS: A minimally invasive approach with antegrade perfusion does not result in increased neurologic complications. Retrograde perfusion, however, is associated with increased neurologic risk in older patients.

Simulating video-assisted thoracoscopic lobectomy: a virtual reality cognitive task simulation.

OBJECTIVE: Current video-assisted thoracoscopic surgery training models rely on animals or mannequins to teach procedural skills. These approaches lack inherent teaching/testing capability and are limited by cost, anatomic variations, and single use. In response, we hypothesized that video-assisted thoracoscopic surgery right upper lobe resection could be simulated in a virtual reality environment with commercial software. METHODS: An anatomy explorer (Maya [Autodesk Inc, San Rafael, Calif] models of the chest and hilar structures) and simulation engine were adapted. Design goals included freedom of port placement, incorporation of well-known anatomic variants, teaching and testing modes, haptic feedback for the dissection, ability to perform the anatomic divisions, and a portable platform. RESULTS: Preexisting commercial models did not provide sufficient surgical detail, and extensive modeling modifications were required. Video-assisted thoracoscopic surgery right upper lobe resection simulation is initiated with a random vein and artery variation. The trainee proceeds in a teaching or testing mode. A knowledge database currently includes 13 anatomic identifications and 20 high-yield lung cancer learning points. The "patient" is presented in the left lateral decubitus position. After initial camera port placement, the endoscopic view is displayed and the thoracoscope is manipulated via the haptic device. The thoracoscope port can be relocated; additional ports are placed using an external "operating room" view. Unrestricted endoscopic exploration of the thorax is allowed. An endo-dissector tool allows for hilar dissection, and a virtual stapling device divides structures. The trainee's performance is reported. CONCLUSIONS: A virtual reality cognitive task simulation can overcome the deficiencies of existing training models. Performance scoring is being validated as we assess this simulator for cognitive and technical surgical education.

Analysis of the mitral coaptation zone in normal and functional regurgitant valves.

BACKGROUND: Functional mitral regurgitation (FMR) is associated with leaflet displacement and tethering. Little is known about regional coaptation zones, including variations in coaptation length (CL) and contributions of anterior and posterior leaflets. Regional coaptation zones were analyzed in patients with normal mitral valves and with FMR. METHODS: Cardiac surgery patients underwent a three-dimensional transesophageal echocardiography. Four-dimensional volumetric datasets were acquired with Doppler interrogation. Offline analysis was performed. Orthogonal views were extracted in diastole and systole. Leaflet dimensions and coaptation distance and depth were examined for posterior and apical displacement of the coaptation zones. RESULTS: Twenty patients were analyzed (10 normal and 10 with 2 to 4+ FMR). Anterior leaflet CL was greater than posterior leaflet CL: 2.2+/-0.6 mm versus 0.9+/-0.3 mm in region 1, 3.2+/-0.7 mm versus 1.2+/-0.6 mm in region 2, and 1.8+/-0.4 mm versus 0.6+/-0.3 mm in region 3 (p<0.001). The FMR was associated with shorter leaflet CLs, with a mean anterior CL of 1.7+/-0.4 mm versus 3.1+/-0.4 mm (p=0.04), and a mean posterior CL of 0.7+/-0.3 mm versus 1.1+/-0.3 mm (p=0.03). The biggest difference in CLs was in A2-P2. Coaptation distance and depth were higher in the FMR group: 21.7+/-1.0 mm versus 17.9+/-1.0 mm (p=0.01), and 8.6+/-0.7 mm versus 5.0+/-0.7 mm (p<0.01). CONCLUSIONS: Mitral valve leaflet CL is asymmetric in normal valves, with anterior dominance. Functional mitral regurgitation is associated with a relocated coaptation zone, regional changes, and diminished coaptation. These data suggest an "anterior leaflet reserve." Posterior movement of the coaptation line compensates for annular dilation and presumed left ventricular enlargement in order to maintain competency until inadequate anterior leaflet CL occurs.