Treatment and Prevention of Cardiovascular Implantable Electronic Device (CIED) Infections.

An expanded role for cardiac implantable electronic devices (CIEDs) in recent decades reflects an aging population and broader indications for devices, including both primary prevention and management of dysrhythmias. CIED infection is one of the most important device-related complications and has a major impact on mortality, quality of life, healthcare utilization, and cost. Unfortunately, the investigation and management of CIED infection remain complex, often necessitating complete and timely removal of the device and leads in order to eradicate the infection. In addition, the translation of knowledge from an extensive literature to a disparate group of medical practitioners has often been inadequate. This review of CIED infection management highlights the significant advances made during the past decade, including diagnostic criteria, advanced imaging, and next-generation sequencing for culture-negative cases or those in which uncertainty remains. We also outline the role and indication for powered lead extraction, the process of antibiotic choice and treatment duration, considerations related to the timing and location for reimplantation, and preimplantation risk stratification and associated interventions to reduce the risk of CIED infection.

L'élargissement du rôle des dispositifs électroniques cardiaques implantables (DECI) au cours des dernières décennies reflète le vieillissement de la population et les indications plus vastes des dispositifs, notamment dans la prévention primaire et la prise en charge des dysrythmies. Les infections liées aux DECI sont l'une des plus importantes complications liées aux dispositifs et ont des conséquences majeures sur la mortalité, la qualité de vie, l'utilisation et les coûts des soins de santé. Malheureusement, le dépistage et la prise en charge des infections liées aux DECI demeurent complexes et nécessitent souvent le retrait complet et rapide du dispositif et des sondes en vue d'éradiquer l'infection. De plus, l'application des connaissances issues d'une vaste littérature à un groupe disparate de médecins praticiens a souvent été inadéquate. La présente revue sur la prise en charge des infections liées aux DECI illustre les avancées importantes réalisées au cours de la dernière décennie, notamment les critères diagnostiques, l'imagerie avancée et le séquençage de prochaine génération des cas à culture négative ou de ceux pour lesquels des incertitudes demeurent. Nous avons aussi décrit le rôle et les indications d'extraction des sondes fonctionnelles, le processus du choix des antibiotiques et de la durée du traitement, les considérations relatives au moment et au lieu de la réimplantation, et la stratification du risque en préimplantation et les interventions associées afin de réduire le risque d'infections liées aux DECI.

PROSE: Prospective Randomized Trial of the On-X Mechanical Prosthesis and the St Jude Medical Mechanical Prosthesis Evaluation: Part 2: Study results-prostheses, positions, and economic development.

Objectives: The Prospective Randomized On-X Mechanical Prosthesis Versus St Jude Medical Mechanical Prosthesis Evaluation (PROSE) trial purpose was to investigate whether a current-generation mechanical prosthesis (On-X; On-X Life Technologies/Artivion Inc) reduced the incidence of thromboembolic-related complications compared with a previous-generation mechanical prosthesis (St Jude Medical Mechanical Prosthesis; Abbott/St Jude Medical). This second report documents the valve-related complications by individual prostheses and by Western and Developing populations. Methods: The PROSE trial study was conducted in 28 worldwide centers and incorporated 855 subjects randomized between 2003 and 2016. The study enrollment was discontinued on August 31, 2016. The study protocol, and analyses of 10 demographic variables and 24 risk factors were published in detail in 2021. Results: The total patient population (N = 855) included patients receiving an On-X valve (n = 462) and a St Jude Medical valve (n = 393). The overall freedom evaluation showed no differences at 5 years between the prostheses for thromboembolism or for valve thrombosis. There were also no differences in mortality. There were several differences between Developing and Western populations. The freedom relations at 5 years for mortality favored Western over Developing populations. Valve thrombosis was differentiated by position and site: aortic < mitral (P = .007) and Western < Developing (P = .005). In the mitral position there were no cases in Western populations, whereas there were 8 in Developing populations (P = .217). Conclusions: The On-X valve and St Jude Medical valve performed equally well in the study with no differences found. The only differentiation occurred with valve thrombosis in the mitral position more than the aortic position and occurring in Developing more than Western populations. The occurrence of valve thrombosis was also related to a younger population possibly due to anticoagulation compliance based on record review.

PROSE: Prospective Randomized Trial of the On-X Mechanical Prosthesis and the St Jude Medical Mechanical Prosthesis Evaluation : Part 1(Patient Dynamics): Preoperative demographics and preoperative and operative risk factors.

OBJECTIVES: The PROSE trial purpose is to investigate whether the incidence of thromboembolic-related complications is reduced with a current generation mechanical prosthesis (On-X Life Technologies/CryoLife Inc.-On-X) compared with a previous generation mechanical prosthesis (St Jude Medical-SJM). The primary purpose of the initial report is to document the preoperative demographics, and the preoperative and operative risk factors by individual prosthesis and by Western and Developing populations. METHODS: The PROSE study was conducted in 28 worldwide centres and incorporated 855 subjects randomized between 2003 and 2016. The study enrollment was discontinued on August 31, 2016. The preoperative demographics incorporated age, gender, functional class, etiology, prosthetic degeneration, primary rhythm, primary valve lesion, weight, height, BSA and BMI. The preoperative and operative evaluation incorporated 24 risk factors. RESULTS: The total patient population (855) incorporated On-X population (462) and the St Jude Medical population (393). There was no significant difference of any of the preoperative demographics between the On-X and SJM groups. The preoperative and operative risk factors evaluation showed there was no significant difference between the On-X and St Jude Medical populations. The preoperative and operative risk factors by valve position (aortic and mitral) also documented no differentiation. The dominant preoperative demographics of the Western world population were older age, male gender, sinus rhythm, aortic stenosis, congenital aortic lesion, and mitral regurgitation. The dominant demographics of the Developing world population were rheumatic etiology, atrial fibrillation, aortic regurgitation, mixed aortic lesions, mitral stenosis and mixed mitral lesions. The Developing world group had only one significant risk factor, congestive heart failure. The majority of the preoperative and operative risk factors were significant in the Western world population. CONCLUSIONS: The preoperative demographics do not differentiate the prostheses but do differentiate the Western and Developing world populations. The preoperative and operative risk factors do not differentiate the prostheses BUT do differentiate the Western and Developing world populations.

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Classification and Surgical Repair of Injuries Sustained During Transvenous Lead Extraction.

BACKGROUND: Injuries to cardiac and venous structures during pacemaker and defibrillator lead extraction are serious complications that have been studied poorly. The incidence of these injuries is unknown but likely underestimated. No systematic multicenter review of these injuries or their management has been undertaken. METHODS AND RESULTS: We interrogated our mandatory administrative database for all excimer laser extractions that sustained a cardiac or venous injury in the province of British Columbia. Injuries were classified according to presentation and compared with respect to nature of injury, type of repair, utilization of cardiopulmonary bypass, and outcome. Of 1082 excimer laser extractions over 19 years, 33 sustained an injury (3.0%). The majority of injuries occurred in women (21/33; 63.6%), and median age of oldest lead extracted was 10.8 (7.5, 12.2) years. A type 1 presentation, defined as circulatory collapse, was found in 12/33 patients (36.4%). A type 2 presentation, defined as progressive hypotension responsive to treatment, was found in 20/33 patients (60.6%). Over half the patients had a moderate or large injury, and cardiopulmonary bypass was required in 13 patients with extensive injury. Despite the presence of devastating injuries, the immediate availability of aggressive salvage measures resulted in a survival of 87.9% of patients at 30 days. CONCLUSIONS: The immediate availability of a cardiovascular surgeon, perfusionist, and cardiopulmonary bypass pump facilitates lifesaving repair of injuries sustained during laser lead extraction. The size and complexity of injury correlates closely with the presentation, blood loss, and need for cardiopulmonary bypass to facilitate repair.

Does reperfusion injury still cause significant mortality after lung transplantation?

OBJECTIVES: Severe reperfusion injury after lung transplantation has mortality rates approaching 40%. The purpose of this investigation was to identify whether our improved 1-year survival after lung transplantation is related to a change in reperfusion injury. METHODS: We reported in March 2000 that early institution of extracorporeal membrane oxygenation can improve lung transplantation survival. The records of consecutive lung transplant recipients from 1990 to March 2000 (early era, n = 136) were compared with those of recipients from March 2000 to August 2006 (current era, n = 155). Reperfusion injury was defined by an oxygenation index of greater than 7 (where oxygenation index = [Percentage inspired oxygen] x [Mean airway pressure]/[Partial pressure of oxygen]). Risk factors for reperfusion injury, treatment of reperfusion injury, and 30-day mortality were compared between eras by using chi(2), Fisher's, or Student's t tests where appropriate. RESULTS: Although the incidence of reperfusion injury did not change between the eras, 30-day mortality after lung transplantation improved from 11.8% in the early era to 3.9% in the current era (P = .003). In patients without reperfusion injury, mortality was low in both eras. Patients with reperfusion injury had less severe reperfusion injury (P = .01) and less mortality in the current era (11.4% vs 38.2%, P = .01). Primary pulmonary hypertension was more common in the early era (10% [14/136] vs 3.2% [5/155], P = .02). Graft ischemic time increased from 223.3 +/- 78.5 to 286.32 +/- 88.3 minutes in the current era (P = .0001). The mortality of patients with reperfusion injury requiring extracorporeal membrane oxygenation improved in the current era (80.0% [8/10] vs 25.0% [3/12], P = .01). CONCLUSION: Improved early survival after lung transplantation is due to less severe reperfusion injury, as well as improvements in survival with extracorporeal membrane oxygenation.

Predictors of recurrence and reoperation for prosthetic valve endocarditis after valve replacement surgery for native valve endocarditis.

OBJECTIVE: Surgical treatment of native valve endocarditis remains challenging, especially in cases with paravalvular destruction. Basic principles include complete debridement and reconstruction. This study is designed to evaluate the outcomes of surgical reconstruction of complex annular endocarditis using standard techniques and materials, including autologous and bovine pericardium. METHODS: From 1975 to 2000, 358 cases (357 patients, mean age 49 +/- 16 years, range 18-88 years) of native valve endocarditis were surgically managed. Bioprosthetic valves were implanted in 189 cases, and mechanical prostheses were implanted in 169 cases. A total of 78 cases of paravalvular destruction were identified: 62 annular abscesses, 8 fistulas, and 8 combined abscesses/fistulas. These were managed with 46 pericardial patches and 32 isolated suture reconstructions after radical debridement and prosthetic valve replacement. RESULTS: The overall early mortality was 8.4% (n = 30). The mortality with paravalvular destruction was 17.9%, and the mortality with simple leaflet infection was 5.7% (P = .001). The unadjusted survival at 20 years was 26.4% +/- 4.9% for bioprosthetic valves and 56.5% +/- 8.1% for mechanical prostheses (P = .007). The freedom from recurrent prosthetic valve endocarditis was 78.9% +/- 4.4% at 15 years. The freedom from reoperation for recurrent prosthetic valve endocarditis was 85.8% +/- 4.2% at 15 years. The freedom from reoperation after reconstruction for paravalvular destruction was 88.2% +/- 6.9% at 15 years. The freedom from mortality for recurrent prosthetic valve endocarditis was 92.7% +/- 3.4% at 15 years. The independent predictors of reoperation were age (hazard ratio 0.930, P = .005) and intravenous drug use/human immunodeficiency virus plus surgical technique (hazard ratio 12.8, P = .003 for patch reconstruction plus valve and hazard ratio 3.6, P = .038 for valve replacement only). Prosthesis type was not predictive when separated from intravenous drug use/human immunodeficiency virus (hazard ratio 3.268, P = .088). CONCLUSION: Paravalvular destruction is associated with a higher operative mortality. Native valve endocarditis can be managed with reasonable long-term survival and low rates of reinfection with radical debridement and pericardial reconstruction with bioprostheses and mechanical prostheses. The type of prosthesis implanted does not influence long-term outcome. Patients with a history of intravenous drug use and human immunodeficiency virus are at increased risk for recurrent infection and reoperation.

Inferior vena cava filter migration to the heart.

Inferior vena cava filters are considered the therapeutic modality for treatment of deep venous thrombosis in patients who are not candidates for anticoagulation therapy. Filter migration to the heart is a rare but serious complication. In this report we present two cases of Inferior vena cava filters that migrated to the heart and how they were managed.

Is mitral valve repair superior to replacement in elderly patients?

BACKGROUND: Mitral valve replacement is more frequently performed and perceived to be equivalent to repair in elderly patients, despite the superiority of repair in younger patients. Our objective was to compare mitral repair to replacement in elderly patients age 75 years or older. Patients younger than 75 years undergoing mitral valve surgery served as a reference population. METHODS: Consecutive elderly patients undergoing operation for mitral regurgitation at our institution from 1998 to 2006 were reviewed. Elderly patients (mean age, 78.0 +/- 2.8 years) who underwent mitral repair (n = 70) or replacement (n = 47) were compared with cohorts of young patients (mean age, 58.9 +/- 9.3 years) who underwent repair (n = 100) or replacement (n = 98) during the same period. Patient details and outcomes were compared using univariate, multivariate, and Kaplan-Meier analyses. RESULTS: Mitral replacement in elderly patients had higher mortality than repair (23.4%, 11 of 47 versus 7.1%, 5 of 70; p = 0.01) or as compared with either operation in the reference group (p < 0.0001). Postoperative stroke was higher in elderly replacement patients compared with repair (12.8%, 6 of 47 versus 0%; p = 0.003) or compared with either young cohort (p = 0.02). Compared with elderly repair patients, elderly replacement patients had more cerebrovascular disease (21.3%, 10 of 47 versus 4.3%, 3 of 70; p = 0.005) and rheumatic mitral valves (21.3%, 10 of 47 versus 0%; p = 0.0001). In the young group, overall complication and mortality were no different between replacement and repair. Long-term survival favored repair over replacement in elderly patients (p = 0.04). One elderly repair patient experienced late recurrence of persistent mitral regurgitation. CONCLUSIONS: In patients age 75 years or older, mitral repair is associated with a lower risk of mortality, postoperative stroke, and prolonged intensive care unit and hospital stay compared with mitral replacement. Mitral repair can be performed in preference over replacement even in patients older than the age of 75.

Statin therapy improves outcomes after valvular heart surgery.

BACKGROUND: The beneficial effects of 3-hydroxy-3-methylglutaryl coenzyme A (HMG Co-A) reductase inhibitors (statins) in patients undergoing coronary artery bypass grafting have been recognized. Reduced mortality rates and clinical events have been demonstrated. These outcomes were examined in patients taking statins who underwent cardiac valve operations. METHODS: This retrospective study included 447 consecutive patients undergoing valve operations between July 2004 and February 2006; 203 patients (45.6%) received statins preoperatively and postoperatively vs 244 who did not. Preoperative risk factors and outcome data for both cohorts were compared. Primary outcomes included 30-day mortality, renal failure, and postoperative stroke. RESULTS: The statin group had more comorbidities. Although they had increased risk factors, including previous stroke (30 of 203 vs 16 of 244, p = 0.004), diabetes (66 of 203 vs 32 of 244, p < 0.0001), cerebrovascular disease (45 of 203 vs 24 of 244, p = 0.003), and dyslipidemia (191 of 203 vs 63 of 244, p < 0.0001), they had better outcomes. The unadjusted odds ratio (OR) for the composite end point of death/stroke/renal failure was 1.90 (95% confidence interval [CI], 0.95 to 3.76; p = 0.068) favoring the statin group. By univariate analysis, the adjusted OR for the composite end point demonstrated a benefit with statin therapy: diabetes, 2.29 (95% CI, 1.16 to 4.71; p = 0.024); stroke, 2.15 (95% CI, 1.06 to 4.35; p = 0.034); and renal dysfunction, 2.05 (95% CI, 1.02 to 4.13; p = 0.045). CONCLUSIONS: Statin therapy in this population undergoing cardiac valve procedures was associated with decreased postoperative morbidity and death. The mechanism may be independent of statins' lipid-lowering effects. A prospective, randomized-control trial of statin therapy in this population is warranted.

Spontaneous hemothorax and neurofibromatosis: a review of a lethal combination.

We present a case report of spontaneous hemothorax associated with neurofibromatosis. On review of the literature, a significant mortality rate of 36% is revealed in addition to a surgical mortality of 33%. Treatment options are reviewed and potential management strategies are discussed.

A change in perspective: results for ischemic mitral valve repair are similar to mitral valve repair for degenerative disease.

BACKGROUND: Although the benefits of mitral valve repair for degenerative disease are well established, many consider surgery for functional ischemic mitral regurgitation (MR) less amenable to operative treatment. We hypothesized that mitral valve repair for ischemic MR results in outcomes similar to those for mitral valve repair for degenerative MR. METHODS: Retrospective review of nonemergent mitral valve repairs for an 8-year period revealed 105 patients with functional ischemic MR, of whom 39 were treated for severe tethering (ischemic group), and 245 patients with degenerative MR (degenerative group). RESULTS: Patients in the ischemic group had more comorbidities (p < 0.01) and worse preoperative left ventricular dysfunction (ejection fraction < or = 0.29) compared with patients in the degenerative group; (ischemic, 37.1% [39 of 105] versus degenerative, 2.0% [5 of 245]; p < 0.01). Immediate postrepair transesophageal echocardiogram revealed a 0 to 1+ MR in all patients in both groups (not significant). The hospital mortality rate was 1.9% (2 of 105) in the ischemic group and 1.2% (3 of 245) in the degenerative group (p = 1.00). The 5-year survival rate was 83.9% in the ischemic group and 94.3% in the degenerative group (p < 0.01). Five-year freedom from reoperation for recurrent MR was 100% and 97.5% in the ischemic and degenerative groups, respectively (p = 0.14). Postoperative renal failure and stroke rates were similar between both groups (not significant). The incidence of moderate or greater MR after more than 1 year of follow-up was similar between groups (not significant). CONCLUSIONS: Despite the multiple comorbidities that afflict patients with ischemic MR, mitral valve repair for ischemic and degenerative disease produces comparable and satisfactory outcomes. An aggressive approach to repair of functional ischemic MR, including treatment of tethering, leads to durable results.

Predicting operative mortality after surgery for ischemic cardiomyopathy.

BACKGROUND: Ischemic cardiomyopathy accounts for as many as 70% of cases of heart failure with no clear algorithm for the treatment. We assessed the operative risks and mortality of various surgical options: coronary artery bypass grafting (CABG), CABG and mitral valve repair (CABG/MVR), and left ventricular remodeling (LVR) with or without CABG. We hypothesized that additional procedures increased the operative risk. We determined whether preoperative variables (eg, urgency of operation) impacted the surgical outcome. METHODS: A retrospective analysis of University of Virginia patients from January 2000 until September 2006 was undertaken. Patients with CABG and an ejection fraction less than 35%, ischemic mitral regurgitation by operative characterization, and patients with LVR were identified. The Society of Thoracic Surgeons database risks, complications, and outcomes as well as degree of revascularization, quality of targets, and type of additional procedures were analyzed. Incomplete revascularization was defined as a planned bypass not performed. Poor targets were defined as per the operative note. RESULTS: In all, 382 patients were identified (220 CABG, 97 CABG/MVR, and 65 LVR). The overall operative mortality was 7.9%. Mortality was 9.1% for CABG, 8.2% for CABG/MVR, and 3.1% for LVR. Preoperative risk factors for mortality included diabetes mellitus (p = 0.05), previous cerebrovascular disease (p = 0.05), and chronic renal dysfunction (p = 0.03). Patients with emergency operations had a significantly increased mortality (p < 0.001) as did patients with intra-aortic balloon pumps (p = 0.015). CONCLUSIONS: Additional procedures such as MVR or LVR did not add to the operative risk of CABG for ischemic cardiomyopathy. Only preoperative comorbidities and emergency operations increased operative mortality.

A simplified approach to degenerative disease: triangular resections of the mitral valve.

BACKGROUND: Only 40% of patients with mitral valve (MV) regurgitation undergo operative repair rather than replacement. Quadrangular resection combined with ring annuloplasty has been the most common method of repair for degenerative posterior leaflet disease. Techniques such as sliding annuloplasty and artificial chord usage have increased the complexity of repair. These techniques have been perceived to be difficult and have possibly reduced the incidence of MV repair. We present our experience with a simplified approach to MV repair utilizing a triangular resection and larger rings. METHODS: Retrospective review of all MV repairs over a 7-year period (1999 to 2006) revealed 154 patients who underwent triangular resection for degenerative disease. Patients who underwent ring annuloplasty without leaflet resection and patients who had artificial chords or quadrangular resections were excluded. RESULTS: Of 154 patients who underwent triangular resection, isolated posterior leaflet resection was performed on 130 patients. Isolated anterior and combined anterior and posterior leaflet triangular resections were performed on 16 and 8 patients, respectively. Thirty-day postoperative mortality was 0%. Five-year freedom from reoperation for recurrent mitral regurgitation was 99.0%. No patients who had intended leaflet resection were converted to MV replacement. Intraoperative transesophageal echocardiogram revealed trace to 1+ mitral regurgitation. Mild systolic anterior motion was noted in 7.1% of cases initially, but resolved with volume loading in all. CONCLUSIONS: Triangular leaflet resection of the mitral valve produces durable results and can be safely and efficiently performed with minimal morbidity and mortality. This technique should allow increased utilization of MV repair for degenerative disease.

Anomalous origin of the right coronary artery: right internal thoracic artery to right coronary artery bypass is not the answer.

OBJECTIVE: Anomalous origin of the right coronary artery from the opposite sinus of Valsalva can be a lethal congenital anomaly. Right internal thoracic artery grafting to the right coronary artery is prone to fail in this circumstance. We sought to describe alternative surgical techniques. METHODS: Retrospective analysis identified 5 adult and pediatric patients in our database. We reviewed the surgical techniques used to repair this anomaly. On the basis of our experience, we describe our management technique. RESULTS: There were no operative deaths, and postoperative computed tomographic scans demonstrated widely patent repairs in all patients. Two patients with previous right internal thoracic artery to right coronary artery grafts presented with occlusion of the right internal thoracic artery. Short-term follow-up demonstrated continued patency. CONCLUSION: Right internal thoracic artery grafting fails in this circumstance, and alternative surgical options provide a good outcome.

Does preoperative ejection fraction predict operative mortality with left ventricular restoration?

BACKGROUND: Ischemic cardiomyopathy and aneurysmal disease have been treated surgically with coronary artery bypass grafting in the past. The Dor technique for left ventricular restoration has demonstrated improved outcomes in patients with ischemic, akinetic ventricles. Our hypothesis was that even marked reduction in preoperative cardiac function (ejection fraction < .25) would not correlate with worse outcomes since the ventricle would be reshaped to improve function. METHODS: A retrospective analysis was performed on all patients who had undergone ventricular restoration with the Dor procedure from January 1996 through September 2005. Patients with a preoperative ejection fraction (EF) < .25 and those with a EF > or = .25 were compared. All Society of Thoracic Surgeons database characteristics, mortality, length of stay (LOS), and need for intraaortic balloon pump (IABP) were analyzed. RESULTS: The study included 89 patients (69 men, 20 women), 28 of whom had preoperative EFs < .25 (mean, .183 +/- .035; range, .08 to .25) and 61 had an EF > or = .25 (mean, .334 +/- .074; mean, .25 to .45). Overall operative mortality was 3.4% (3/89), with no statistically significant difference between the two groups (3.6% versus 3.3%). LOS was 7.4 +/- 3.6 days versus 8.9 +/- 15.6 days (p = NS), and need for IABP was 39.2% versus 8.1% (p < 0.05). Overall 5-year survival was 82%. Five-year survival in the EF < .25 cohort was 69.6% versus 88.3% in the EF > or = .25 cohort (p = 0.066). CONCLUSIONS: Ventricular restoration with the Dor technique is a safe procedure. Marked reduction in ejection fraction is not a contraindication to left ventricular restoration; however, increased usage of IABP should be anticipated.

An unusual case of cardiac dysfunction after left ventricular reconstruction.

This report describes an unusual cause of low cardiac output after coronary artery bypass grafting and left ventricular remodeling. It details left ventricular remodeling techniques and discusses the most recent advances and outcomes. As well, significant attention is paid to the issues surrounding failure to separate from cardiopulmonary bypass.

Aortic arch reconstruction: safety of moderate hypothermia and antegrade cerebral perfusion during systemic circulatory arrest.

BACKGROUND AND AIM: The ideal strategy for cerebral protection during aortic arch (AA) reconstructive surgery remains undefined. Antegrade cerebral perfusion (ACP) during systemic circulatory arrest (SCA) may provide superior results; however, optimal systemic temperature is undetermined. Our objective was to determine whether "deep" hypothermia is necessary during ACP with SCA, and whether the degree of hypothermia is associated with neurologic outcomes postoperatively. METHODS: Retrospective series of 72 consecutive patients (aged 65.9 +/- 3.2 years) who underwent AA reconstructive surgery at Vancouver General Hospital using a cerebral protection strategy of ACP with SCA between December 1995 and December 2002. Patients were divided into two groups according to lowest systemic temperature: <22 degrees C (n = 52) and > or =22 degrees C (n = 20). RESULTS: ACP was via right axillary or innominate artery, +/- left common carotid cannulation. Median SCA time with ACP was not different between groups. There were four hospital deaths (5.6%) (three from the <22 degrees C group). Eight patients (11.2%) had major neurologic injuries (seven from the <22 degrees C group): 4 (5.6%) permanent (1 fatal) and 4 (5.6%) temporary. There was a trend toward a significantly higher incidence of delirium in the <22 degrees C group than the > or =22 degrees C group (30.8 vs 10.0%, respectively, p = 0.07). CONCLUSIONS: In our experience, SCA with ACP was a safe technique for AA reconstructive surgery. The observation of a larger number of major neurologic injuries, and a trend toward a higher incidence of delirium in the <22 degrees C group, suggests that systemic temperatures below 22 degrees C may not be necessary and may be associated with a higher incidence of neurologic injury when using ACP during SCA.