Impact of a focused review course in cardiovascular and thoracic surgery on test performance.

Background: The Core Curriculum Review Course in Cardiovascular and Thoracic Surgery is a 4-day educational program consisting of 77 didactic lectures that provide a comprehensive review of the material required for surgeons preparing for the American Board of Thoracic Surgery competency written examination. The lectures are supplemented with a written syllabus and interactive audience participation system. We sought to determine whether participation in this course could improve participants' performance on a cardiothoracic subject-based test. Methods: Sixty-five participants attended the 2018 course. Before beginning the course lectures, a multiple-choice pretest consisting of 77 questions was administered via mobile application to gauge the participants' baseline knowledge. A second multiple-choice posttest was made available beginning 7 weeks after the course, also by mobile application. Results: Twenty-nine participants completed both the pretest and the posttest. The median pretest score was 47% (36 of 77 correct answers). The median posttest score was 61% (47 of 77 correct answers), representing an increase of 14%. The Wilcoxon signed-rank test indicated a significant difference between the pretest and posttest scores (z = -4.36; P = .00). Overall, 25 participants (86%) improved their posttest score. Conclusions: The core curriculum review course was successful in improving participants' performance on the course tests, indicating that the participants' fund of knowledge was likely increased by attendance at the program. Additional strategies should be considered to address particular areas of study both for individual participants and for residents currently in training.

BioGlue: a protective barrier after pericardiotomy.

BACKGROUND: Repeat operation on the heart composes about 20% of procedures in contemporary practice of cardiac surgery. A sheet of material providing a barrier against cardiac adhesion to the sternum would be desirable. METHODS: Anterior pericardiectomy was performed in rats. BioGlue milled to a 0.4 mm sheet was applied to the anterior surface of the heart in 16 rats; Surgicel plus liquid BioGlue in seven; Surgicel alone in three; and nothing (control) in eight. The operative site was reexamined for gross evidence of adhesion, scarring, and residual BioGlue 1, 3, and 6 months later. RESULTS: There was formation of a loose connective tissue barrier containing blood vessels without scar formation in all animals treated with milled BioGlue. Surgicel plus BioGlue resulted in a barrier containing more denser connective tissue with collagen fibers. Surgicel alone resulted in a similar barrier. No barrier formed in the control experiments. CONCLUSIONS: A sheet of milled BioGlue applied over the surface of the heart but not attached to it after partial pericardiectomy has been shown to stimulate formation of a loose connective tissue barrier containing blood vessels. This barrier is unique compared to dense fibrous scar which usually forms after opening the pericardium for cardiac operations.

Comparison of standard Maze III and radiofrequency Maze operations for treatment of atrial fibrillation.

OBJECTIVE: This study compares clinical results of the standard Maze III operation, a highly effective treatment for atrial fibrillation, to less complex variations of the Maze III operation utilizing unipolar and bipolar radiofrequency ablation and pulmonary vein isolation. METHODS: Records were reviewed of 377 patients who had operations for treatment of atrial fibrillation at a single institution over a 10-year period. Standard Maze III was performed in 220 patients, unipolar radiofrequency Maze III in 60, bipolar radiofrequency Maze III in 65, and radiofrequency pulmonary vein isolation in 32. Electrocardiograms were obtained at discharge and 3-, 6-, and 12-month intervals. Chi-square test, logistic regression, and Bayesian theory analyses were performed to determine significant associations between operative procedures and outcomes. RESULTS: Mean age was 65.1 years (range 22-87). There were 13 hospital deaths (3.4%) and 16 deaths during follow-up. Most patients (90.2%, 340/377) had concomitant operations. Electrocardiogram analysis was available in 344 patients at 3 months and 313 patients at 6 months. Freedom from atrial fibrillation at 6 months was superior after standard Maze III compared with radiofrequency modifications. Subanalysis according to surgeon experience demonstrated good results regardless of operative experience. CONCLUSIONS: This single-institution experience suggests that the standard Maze III operation is superior to radiofrequency operations for treatment of atrial fibrillation. Radiofrequency modifications of the Maze III operation are also effective treatments for atrial fibrillation and can achieve good results regardless of surgeon experience.

Left atrial sarcoma: resection and repair by cardiac autotransplant and in situ pericardial patch.

This report demonstrates the method of resection of a left atrial tumor involving the right superior pulmonary vein. The unique features are use of adjacent pericardium as an in situ patch to reconstruct the left atrium when there is no margin of left atrium remaining on the pulmonary veins and cardiac autotransplantation.

Tricuspid valve replacement after cardiac transplantation.

BACKGROUND: Tricuspid valve insufficiency (TI) is common after orthotopic heart transplantation. However, tricuspid valve replacement or repair (TVR) is rare. The aim of this study is to evaluate our experience with TVR in cardiac transplant recipients. METHODS: The Utah Transplantation Affiliated Hospitals (UTAH) Cardiac Transplant Program database was queried for TVR in all adult and pediatric heart transplant recipients. Pre-operative parameters and cardiac hemodynamics were compared with post-operative findings. RESULTS: Since 1985, we identified in our database 17 patients who had 16 TVR, and 2 tricuspid valve repair procedures. Thirty-four heart transplant recipients from the same period were used as controls. The indication for TVR was symptomatic right heart failure (RHF) in 89% of cases, and there was no significant difference between the control group and the surgery group in the average number of biopsies. A flail leaflet was found in 16 cases (89%). One patient died post-operatively due to cardiogenic shock, and 1 patient died 8 months after TVR due to progressive RHF. Improvement in heart failure symptoms was seen in 12 cases. The central venous pressure (CVP) decreased from 17.8 +/- 4.1 mm Hg to 11.0 +/- 7.3 mm Hg (p = 0.013). There was no significant change in cardiac output or renal function. However, the furosemide dose decreased significantly from 47.69 +/- 56.44 mg/day to 26.54 +/- 46.43 mg/day (p = 0.009). CONCLUSIONS: After orthotopic heart transplantation, TVR is a safe and effective procedure to alleviate RHF symptoms. Flail leaflets are the most common operative finding, suggesting that biopsy-induced trauma is the likely cause of severe TI in these patients.

Single ventricle palliation: greater risk of complications with the Fontan procedure than with the bidirectional Glenn procedure alone.

BACKGROUND: This study was performed to evaluate and compare the early, intermediate, and long-term outcomes of the bidirectional Glenn procedure and Fontan procedure in patients who live at moderately high altitude. METHODS: The outcome of each method of palliation for patients with a functionally single ventricle was retrospectively evaluated from a review of medical records. RESULTS: The bidirectional Glenn procedure was performed in 177 patients from October 1984 to June 2004. The Fontan procedure was performed in 149 patients from June 1978 to June 2004. Cardiovascular death or heart transplantation occurred in 8% of patients after the bidirectional Glenn procedure and 17% of patients after the Fontan procedure. Complications of systemic thromboembolic events, bleeding associated with anticoagulation therapy, protein losing enteropathy, and arrhythmias requiring implantation of a pacemaker, cardioversion, or radiofrequency ablation occurred in 7% of patients after the bidirectional Glenn procedure and 47% of patients after the Fontan procedure. Cardiovascular deaths and heart transplantation occurred less frequently when the Fontan procedure was performed in patients with a previous bidirectional Glenn procedure. However, the actuarial transplant-free survival and freedom from complications was not superior for a subgroup of patients who had a Fontan procedure after a bidirectional Glenn procedure in comparison to a subgroup of patients who had a bidirectional Glenn procedure alone. CONCLUSIONS: The bidirectional Glenn procedure can be used for long-term palliation of patients with a functionally single ventricle. Additional palliation with a Fontan procedure may increase the risk of stroke, protein losing enteropathy and arrhythmias without improving survival.

Ten-year outcome after aortic valve replacement with the freestyle stentless bioprosthesis.

BACKGROUND: Stentless aortic bioprostheses offer excellent hemodynamics and potentially improved durability compared with other bioprostheses. The present report describes the clinical and hemodynamic outcomes for the Freestyle aortic root bioprosthesis in a large, multicenter cohort prospectively followed up for 10 years. METHODS: A total of 725 patients at 8 centers in North America (668 [92%] aged more than 60 years) were followed up prospectively after aortic valve replacement with the Freestyle stentless bioprosthesis. Implant technique was subcoronary in 509, total root in 178, and root inclusion in 38. Follow-up was 4,488 patient-years (mean 6.2 years/patient). RESULTS: For subcoronary, full root, and root inclusion groups, 10-year actuarial freedom from structural valve deterioration was 97.0% +/- 2.2%, 96.0% +/- 4.5%, and 90.9% +/- 11.2%, respectively; and actuarial freedom from reoperation was 91.7% +/- 3.5%, 92.3% +/- 6.0%, and 92.0% +/- 10.7%, respectively. Mean pressure gradient at 10 years was 8.9 +/- 7.9 mm Hg for subcoronary, 7.0 +/- 4.1 mm Hg for full root, and 10.0 +/- 11.1 mm Hg for root inclusion groups; effective orifice area was 1.6 +/- 0.5 cm2, 1.6 +/- 0.6 cm2, and 1.7 +/- 0.5 cm2, respectively. Fredom from moderate or more aortic regurgitation at 10 years was good for all three implant groups, but slightly higher for full root (97.7% +/- 1.6%) compared with subcoronary (87.2% +/- 2.8%) patients (p < 0.005). CONCLUSIONS: The Freestyle stentless aortic root bioprosthesis is a versatile option for aortic valve replacement. Measures of clinical outcomes and prosthesis durability remain excellent through 10 years.

Early postoperative use of unfractionated heparin or enoxaparin is associated with increased surgical re-exploration for bleeding.

BACKGROUND: A variety of indications (eg, prosthetic heart valves, atrial fibrillation, etc.) exist for the use of unfractionated heparin (UFH) and enoxaparin (ENOX) in the early postoperative period following open-heart surgery. However, the overall postoperative risk for hemorrhage from the use of UFH and ENOX are not known. METHODS: From 1998 to 2001, 2,977 consecutive open-heart or valve surgery patients were retrospectively evaluated. Postoperatively, 2,037 received no UFH or ENOX, 579 received intravenous UFH, and 361 received ENOX. Baseline characteristics were collected, patients who required surgical re-exploration for postoperative bleeding and time between surgery and re-exploration were followed-up. RESULTS: Average patient ages were 64 +/- 13, 65 +/- 12, and 68 +/- 10 years receiving none, UFH (p < 0.01 vs none), and ENOX (p < 0.01 vs none; p < 0.01 vs UFH), respectively. Rates of surgical re-exploration were 2.7% for none, 7.8% for UFH, and 8.9% for ENOX (vs none, adjusted hazard ratio = 2.8; p < 0.001 for UFH; hazard ratio = 3.3; p < 0.001 for ENOX). Males were also at higher risk for re-exploration (hazard ratio = 1.4; p = 0.07). For those requiring re-exploration, the interval between surgery and first re-exploration was prolonged (> 4 days) among those receiving ENOX (37.5%, odds ratio = 36.7; p = 0.001) and UFH (20.0%, odds ratio = 14.7; p = 0.01) compared with none (1.8%). Prolonged times with ENOX had a greater proportion of prolonged times than UFH (odds ratio = 2.5; p = 0.09). CONCLUSIONS: Early postoperative use of ENOX and UFH is associated with a significant increase in re-exploration for postoperative bleeding, often at a significantly delayed time period after the initial surgery. This delay was especially common with ENOX suggesting the need for prospective studies.

Early failure of a tricuspid valve replacement with a mitral valve homograft in a heart transplant recipient.

A 24-year-old woman experienced severe tricuspid valve regurgitation 6 years after heart transplantation. Tricuspid valve replacement was performed using a cryopreserved mitral valve homograft. Severe tricuspid valve regurgitation recurred within 4 months, associated with an increase in the panel reactive antibody titers from zero to 72%. Tricuspid valve replacement was repeated with a porcine bioprosthesis with excellent recovery and function for >2 years. The mitral valve homograft displayed inflammatory features consistent with humoral immune-mediated destruction.

Current status of surgery for rheumatic carditis in children.

BACKGROUND: The incidence of rheumatic heart disease (RHD) has increased recently in the western United States. We reviewed our 18-year surgical experience with RHD in children to examine current surgical techniques and results. METHODS: From 1985 until 2003, 596 children (<21 years) with rheumatic fever were seen at Primary Children's Medical Center. Rheumatic carditis was diagnosed in 366 patients (61.4%). Twenty-six with carditis (26/366, 7.1%) required operation for rheumatic valve disease including 8 for mitral regurgitation, 7 for mitral and aortic regurgitation, 4 for aortic regurgitation, 4 for mitral regurgitation and stenosis, 2 for combined mitral stenosis and regurgitation with aortic insufficiency, and 1 for mitral and tricuspid regurgitation. RESULTS: Mean age at operation was 13.5 +/- 4 years. Three patients required operation during the acute phase of rheumatic fever (< 6 weeks), 2 during the subacute phase (< 6 months), and 21 during the chronic phase after the episode of rheumatic fever (6.7 +/- 3 years). Mitral valve repair was possible in 19 of 22 patients who required mitral operation. Aortic valve repair was possible in 4 patients whereas replacement was necessary in 9, including 2 Ross procedures. No operative deaths were recorded and 2 late deaths occurred at 4.6 and 10 years. Actuarial survival was 94% at 5 years and 78% at 10 years. Six patients required reoperation; actuarial freedom from reoperation was 78% at 5 years, 65% at 10 years, and 49% at 15 years. All survivors are in New York Heart Association class I or II. CONCLUSIONS: Children with RHD in the United States uncommonly require valve operation. Mitral repair with a technique that allows annular growth is possible in most children with good long-term functional results. Long-term surveillance of children with RHD is necessary because of the possible need for late valve operation.

Eight-year results after aortic valve replacement with the Freestyle stentless bioprosthesis.

OBJECTIVES: We sought to describe the hemodynamic and clinical outcomes for the Freestyle aortic root bioprosthesis (Medtronic, Inc, Minneapolis, Minn) in a large multicenter cohort prospectively followed for 8 years. METHODS: A total of 700 patients (651 [93%] >60 years of age) at 8 centers in North America were followed prospectively after aortic valve replacement with the Freestyle stentless bioprosthesis; the implant technique was subcoronary in 500, total root in 162, and root inclusion in 38. Follow-up was 3395 patient-years (4.9 +/- 2.3 years per patient). Clinical and echocardiographic follow-up was prospectively obtained at yearly intervals. RESULTS: For the subcoronary, total root, and root inclusion groups, actuarial freedom from valve-related death was 96.8% (SE 3.0%), 92.3% (SE 7.7%), and 90.9% (SE 11.2%), respectively, and freedom from structural deterioration was 98.6% (SE 2.0%), 100.0% (SE 0.0%), and 100.0% (SE 0.0%), respectively. Hemodynamics remained excellent at 6 years. Freedom from moderate or more aortic regurgitation was 86.0% (SE 5.1%), 98.7% (SE 3.9%), and 97.3% (SE 6.6%), respectively. Gradients were slightly lower (P =.0009), and the effective orifice area (P =.02) and freedom from aortic regurgitation were slightly higher (P =.03) with total root than subcoronary implantation. CONCLUSIONS: The Freestyle stentless aortic root bioprosthesis is a versatile option for aortic valve replacement. Measures of clinical outcomes and prosthesis durability remain excellent in multicenter follow-up through 8 years in a population predominantly older than 60 years at the time of the operation.

Surgical treatment of atrial fibrillation.

This article reviews the fundamentals of surgical treatment of atrial fibrillation. The clinical classification, pathophysiology, medical treatment strategy, and catheter-based interventions are also included. The Cox-Maze III procedure was developed over based on experiences of several operations which proceeded it. The operation is complex but results are excellent with over 90% of patients in normal sinus rhythm or regular atrial rhythm. Several modifications have been devised using various energies to ablate atrial myocardium as a means of extending surgical incisions to simplify the Maze III operation. Techniques and results of these operations are reviewed. Modified operations offering about 80% restoration of sinus rhythm are attractive to more surgeons because of the reduced complexity and time of operation.

Blunt chest trauma: an experimental model for heart and lung contusion.

BACKGROUND: Blunt chest trauma is an important clinical problem leading to injury of the heart and lungs that may be fatal. Experimental models in large animals have been developed previously. This study was aimed at developing a small-animal (rat) model for the purpose of evaluating blunt chest trauma. METHODS: Blunt trauma was delivered to the left side of the chest in rats by a captive bolt handgun. The gun was modified so that the amount of energy delivered to the chest wall could be adjusted. The injury energy varied from 1.7 to 6.8 J. Thirty-eight experiments in adult rats were performed. Electrocardiographic monitoring was performed continuously to determine cardiac rhythm. Gross and histologic examination of lungs and heart was performed at the time of death resulting from injury or euthanasia up to 13 days after injury. RESULTS: Some form of cardiac arrhythmia accompanied blunt chest trauma in every case. Serious ventricular arrhythmia (tachycardia or fibrillation) was nearly always fatal (15 of 16 cases), but gross or histologic evidence of cardiac injury was present in only 31% of fatal cases. Lung injury (often bilateral) as shown by atelectasis and hemorrhage into the parenchyma or airway was found in 93% of the experiments when medium range energy force was applied. CONCLUSION: This study has established a useful model for the study of blunt chest trauma in a small animal (rat). Blunt chest trauma is associated with cardiac arrhythmia, which may be fatal. Injury to the heart may not correlate with serious cardiac arrhythmia resulting in death, lending credence to the concept of cardiac concussion or commotio cordis. Lung contusion is always more obvious than morphologic injury to the heart.

Impact of implant technique following freestyle stentless aortic valve replacement.

BACKGROUND: Stentless aortic bioprostheses have excellent hemodynamics and clinical outcomes. The purpose of the present study was to determine whether implant technique of the Freestyle aortic root bioprosthesis impacts clinical outcomes or hemodynamic performance. METHODS: The long-term multicenter study of the Freestyle stentless aortic bioprosthesis includes 500 consecutive patients implanted using the subcoronary and 162 using the full root technique. Clinical outcomes and echocardiographic hemodynamics were compared through 5 years. RESULTS: There were no differences between groups in time to death, valve-related death, or reoperation. The incidence of operative death was higher in the full root than in the subcoronary group (odds ratio 3.97, p = 0.001). Patients in the subcoronary group were more likely to have New York Heart Association functional class III or IV symptoms at 1 year (1.7% versus 0%, p = 0.04) and 5 years postoperatively (4.4% versus 0%, p = 0.02). Mean gradient was lower (p = 0.0004) and effective orifice area larger (p = 0.04) in the full root group. Left ventricular mass index decreased in both groups. The preponderance of patients in both groups had no or trivial aortic regurgitation through 5 years. CONCLUSIONS: Full root implantation of the Freestyle stentless aortic bioprosthesis was associated with higher operative mortality, but somewhat better hemodynamics, functional class, and freedom from aortic regurgitation. Higher operative mortality argues against the empiric replacement of the ascending aorta in the absence of aortic root pathology. In appropriately selected patients, both implant techniques are viable alternatives for valve implantation.

Repair of transverse sternal nonunions using metal plates and autogenous bone graft.

Transverse sternal nonunion is a complication of sternal fracture or partial sternotomy, and requires surgical treatment. Three patients with repeated failure of standard sternal repair were treated with a technique using metal plates and autogenous bone graft, which resulted in bone union in all patients. Metal plating of the sternum, accompanied by autogenous bone graft, is an effective method of treating transverse sternal nonunion.