Impact of Surgical Experience on Operative Mortality After Reoperative Cardiac Surgery.

BACKGROUND: Learning curves and skill attrition with aging have been reported to impair outcomes in select surgical subspecialties, but their role in complex cardiac surgery remains unknown. METHODS: From 1986 to 2019, 2314 patients underwent reoperative cardiac surgery: coronary artery bypass grafting (n = 543), valve (n = 1527), or combined coronary artery bypass grafting and valve (n = 244). Thirty-four different surgeons in practice between 1 and 39 years were included. Standardized mortality ratio (observed-to-expected) was determined for all surgeons in each post-training year of experience. RESULTS: Risk-adjusted cumulative sum change-point analysis was used to define five distinct career phases: 0 to 4 years, 5 to 8 years, 9 to 17 years, 18 to 28 years, and 29 to 39 years. With 5 to 8 years and 18 to 28 years of experience, standardized mortality ratio was near unity (0.95 and 1.05, respectively) and lowest with 9 to 17 years of experience (0.78, P = .03). In the youngest experience group (0 to 4 years), observed and expected mortality were both highest, and standardized mortality ratio was elevated at 1.29, which approached statistical significance (P = .059). In the oldest experience group (29 to 39 years), expected mortality was low compared with most other groups but observed mortality increased, yielding a significantly elevated standardized mortality ratio at 1.53 (P = .032). CONCLUSIONS: Standardized mortality ratios with reoperative cardiac surgery were highest early and late in a surgeon's career and lowest in mid career. As surgeons gain experience, outcomes improve through the first two career decades, then stabilize in the third decade before declining in the fourth decade.

Clinical Outcomes and Reduced Pulmonary Artery Pressure With Intra-Aortic Balloon Pump During Central Extracorporeal Life Support.

Patients supported with extracorporeal life support (ECLS) can experience severe complications from increased left ventricular afterload. The intra-aortic balloon pump (IABP) is thought to unload the left ventricle (LV) and is routinely used with ECLS despite conflicting evidence of its clinical benefit. This retrospective, single-center study examined the effect of the simultaneous use of IABP and centrally cannulated ECLS on patient outcomes and provides new insights into IABP-mediated LV unloading. Thirty patients supported with central ECLS and IABP (extracorporeal life support-IABP group, ECLS-I) were compared with 30 patients with central ECLS alone (ECLS) for cardiogenic shock. Rates of survival to 30 days (p = 0.06) and intensive care unit (ICU) discharge (p = 0.17), and clinical outcomes were not significantly different between the two groups. In patients with pulmonary artery pressure monitoring, mean pulmonary artery (PA) pressure was significantly reduced after 24 (p = 0.007) and 48 hours (p = 0.002) in the ECLS-I group. No significant difference in PA pressure was observed in the ECLS group after 24 or 48 hours. The IABP has the ability to reduce pulmonary artery pressure in patients supported by central ECLS. However, this did not translate into improved survival or clinical outcomes in our population.

Left Ventricular Unloading by Impella Device Versus Surgical Vent During Extracorporeal Life Support.

BACKGROUND: Patients supported with extracorporeal life support (ECLS) can experience severe complications from increased left ventricular (LV) afterload. The Impella (Abiomed, Danvers, MA) percutaneous ventricular assist device (PVAD) may offer an attractive option for unloading the LV in these patients. This study describes the efficacy and outcomes of PVAD use during ECLS compared with surgically placed LV vent. METHODS: In this retrospective study, we reviewed patients supported by ECLS with PVAD or surgical LV vent for cardiogenic shock between April 2010 and May 2016. Included were 23 patients with PVADs and 22 with surgical vents. Patients' baseline characteristics, hemodynamic data, and outcomes were collected immediately preceding combined support initiation, at 48 hours, intensive care unit discharge, and 30 days. RESULTS: After 48 hours, pulmonary artery diastolic pressure was significantly reduced in the PVAD (23.3 ± 8.4 vs 15.6 ± 4.2, p = 0.02) and surgical vent groups (20.1 ± 5.9 vs 15.6 ± 5.4, p = 0.01), and radiographic evidence of pulmonary edema was reduced or unchanged in 90% of PVAD patients and in 76% of surgical vent patients. The primary end points of survival to 30 days (43% vs 32%, p = 0.42) and intensive care unit discharge (35% vs 23%, p = 0.37) were not different between the two methods of support. The PVAD and surgical vent groups were also not significantly different in the rate of vascular complications or in the number decannulated from ECLS and transitioned to durable LV assist device. CONCLUSIONS: PVAD use in ECLS patients is an effective means of LV unloading and preventing worsened pulmonary edema, with outcomes and complications that are comparable to surgical LV vent.

Extracorporeal Left Ventricular Circulatory Support as a Bridge to Implantable LVAD for a Patient With Pan-Left Ventricular Thrombosis.

We present the case of a 57 year old woman who developed pan-left ventricular thrombus while being supported with central extracorporeal membrane oxygenation support for cardiogenic shock. The left heart thrombus was evacuated emergently through the aortic valve, left atriotomy, and left ventriculotomy. The cannulation was then revised with the addition of a 36 French angled cannula in the apex of the left ventricle to decompress the ventricle, minimize stasis, and allow for any residual microthrombus to be trapped in the oxygenator membrane, not causing embolization. Once her neurological status was confirmed intact, a durable device was implanted. She recovered well without any neurological injury.

Case report of fetal axillo-thoraco-abdominal cystic hygroma.

Cystic hygroma (moist tumor) was first described in 1828 by Redenbacher. The cyst usually results owing to an absence or an inefficient connection between the lymphatic and venous systems. Of this type of malformation 75% cases are localized in the nuchal region; however, only 20% are found in the axilla while 5% of these hygromas are in other locations. Prognosis depends on associated fetal co-morbidities. There are many case reports on cystic hygroma but only a few on the axillo-thoraco-abdominal variant. This is a case report of a huge late-onset fetal axillo-thoraco-abdominal cystic hygroma, which was diagnosed at term followed by a difficult vaginal delivery in a 38-year-old woman. The baby did not have any congenital anomaly other than cystic hygroma with no evidence of intrathoracic or intra-abdominal extension of mass and a pelvic kidney reported on neonatal ultrasound and CT scan. The surgical excision of the cyst was done on the fourth day following birth and the histopathology report confirmed the diagnosis. Management of fetal cystic hygroma with the use of a sclerosing agent is a new modality being explored. Risk of recurrence in subsequent pregnancies for aneuploidy is not increased. The baby has been followed up to 5 months of birth and is thriving well. Karyotype shows an XX pattern.