Edge-to-edge with partial band mitral valve repair compared to replacement and undersized restrictive annuloplasty for ischemic mitral regurgitation.

Objective: Evidence supports replacement over repair for ischemic mitral regurgitation due to improved durability; however, the latter often involves an undersized ring annuloplasty that does not include edge-to-edge approximation. The objective of this study was to evaluate the outcomes of replacement, edge-to-edge leaflet approximation with mild-undersized annuloplasty and undersized ring annuloplasty for ischemic mitral regurgitation. Methods: This is a single-center retrospective study of patients undergoing mitral surgery for moderate-severe or greater ischemic mitral regurgitation, between 2004 and 2020, with mild-undersized annuloplasty, mitral valve replacement, or undersized restrictive annuloplasty (undersized ring annuloplasty). The primary outcome was all-cause mortality. Secondary outcomes included first recurrence of mitral regurgitation, heart failure hospitalization, and composite of valve-related events (bleeding, thromboembolism, endocarditis, and mitral valve reoperation). Results: There were 121, 93, and 78 patients in the mitral valve replacement, mild-undersized annuloplasty, and undersized restrictive annuloplasty groups, respectively, with a median follow-up of 3.1, 5.9, and 3.8 years, respectively. Both mitral valve replacement (hazard ratio, 1.87; 95% CI, 1.029-3.415) and undersized restrictive annuloplasty (hazard ratio, 2.73; 95% CI, 1.480-5.061) were associated with worse survival compared with mild-undersized annuloplasty. At 2 years, the rate of mild-moderate mitral regurgitation was greater in the mild-undersized annuloplasty group compared with the mitral valve replacement group (P = .001) but less than in the undersized restrictive annuloplasty group (P = .001). The rate of recurrent moderate or greater mitral regurgitation at 2 years was similar between mild-undersized annuloplasty and mitral valve replacement groups but significantly higher after undersized restrictive annuloplasty (P < .0001). Mitral valve replacement and undersized restrictive annuloplasty were associated with a significant increase in the incidence of first heart failure hospitalization compared with mild-undersized annuloplasty (P < .001 and P = .001, respectively). Mitral valve replacement was associated with an increased incidence of valve-related events compared with mild-undersized annuloplasty (P = .002). Conclusions: Surgical edge-to-edge approximation in addition to a mild-undersizing annuloplasty offers similar durability compared with replacement, with a lower rate of hospitalization for heart failure, and may confer a survival advantage.

Minimally Invasive Coronary Artery Bypass Grafting in a Patient With Chronic Tracheostoma: Alternative to Reduce Sternal Wound Complication Risk.

Patients with chronic tracheostoma present a challenge when they require coronary bypass surgery due to an elevated risk of sternal wound infections (SWI). Minimally invasive coronary artery bypass grafting (MICS CABG) is a robust technique that allows complete surgical revascularization while mitigating the risks of sternal complications and functional decline associated with sternotomy. In such patients at elevated risk for SWI, MICS CABG may represent a viable revascularization strategy to avoid sternotomy. Here, we present a case of a frail, comorbid patient with a chronic tracheostomy and symptomatic multivessel coronary artery disease not amenable to percutaneous therapy referred for MICS CABG.

A standardized definition for right ventricular failure in cardiac surgery patients.

Right ventricular failure (RVF) is a significant cause of mortality and morbidity after cardiac surgery. Despite its prognostic importance, RVF remains under investigated and without a universally accepted definition in the perioperative setting. We foresee that the provision of a standardized perioperative definition for RVF based on practical and objective criteria will help to improve quality of care through early detection and facilitate the generalization of RVF research to advance this field. This article provides an overview of RVF aetiology, pathophysiology, current diagnostic modalities, as well as a summary of existing RVF definitions. This is followed by our proposal for a standardized definition of perioperative RVF, one that captures RV structural and functional abnormalities through a multimodal approach based on anatomical, echocardiographic, and haemodynamic criteria that are readily available in the perioperative setting (Central Image).

Unexplained fever following DeBakey type I aortic dissection repair with woven Dacron grafts.

Transient fever is not uncommon postcardiac surgery, usually related to underlying clinical process such as inflammation related to the physiological insult or infection. Here, we present a case series of two patients who underwent repair for type A aortic dissection with Gelweave graft prosthesis who had persistent fevers, leukocytosis, and raised inflammatory markers persisting months after surgery. Both patients were found to have sterile perigraft fluid collections. Comprehensive investigations excluded common causes of postoperative inflammation, as well as rarer causes of fever of unknown origin. The presence of this idiopathic inflammatory state lead to extended hospitalization and resource utilization, prompting need for further characterization of its mechanism and proper management.

Aortic arch surgery at 32°C: mild hypothermia and unilateral antegrade cerebral perfusion.

OBJECTIVES: With development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To minimize the adverse effects of hypothermia, surgeons now perform these procedures closer to normothermia. This study examined postoperative outcomes of hemiarch replacement patients using unilateral selective antegrade cerebral perfusion and mild hypothermic CA. METHODS: Single-centre retrospective review of 66 patients undergoing hemiarch replacement with mild hypothermic CA (32°C) and unilateral selective antegrade cerebral perfusion between 2011 and 2018. Antegrade cerebral perfusion was delivered using right axillary artery cannulation. Postoperative data included death, neurological dysfunction, acute kidney injury and renal failure requiring new dialysis. Additional intraoperative metabolic data and blood transfusions were obtained. RESULTS: Eighty-six percent of patients underwent elective surgery. Mean age was 67 ± 3 years. Lowest mean core body temperature was 32 ± 2°C. Average CA was 17 ± 5 min. No intraoperative or 30-day mortality occurred. Survival was 97% at 1 year, 91% at 3 years and 88% at 5 years. Permanent and temporary neurological dysfunction occurred in 1 (2%) and 2 (3%) patients, respectively. Only 3 (5%) patients suffered postoperative stage 3 acute kidney injury requiring new dialysis. Intraoperative transfusions occurred in 44% of patients and no major metabolic derangements were observed. CONCLUSIONS: In patients undergoing hemiarch surgery, mild hypothermia (32°C) with unilateral selective antegrade cerebral perfusion via right axillary cannulation is associated with low mortality and morbidity, offering adequate neurological and renal protection. These findings require validation in larger, prospective clinical trials.

Appropriate therapy for patients with stable ischemic heart disease: a review of literature and the implication of the International Study of Comparative Effectiveness with Medical and Invasive Approaches trial.

PURPOSE OF REVIEW: The aim of this review is to review the current literature on the management of stable ischemic heart disease in light of findings from the International Study of Comparative Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial. RECENT FINDINGS: Compared with optimal medical therapy, coronary artery bypass grafting (CABG) has been shown to improve survival and incidence of myocardial infarction in patients with stable ischemic heart disease whereas percutaneous coronary intervention (PCI) has not. The ISCHEMIA trial compared an initial conservative management strategy with optimal medical therapy with an initial invasive strategy with coronary angiogram followed by revascularization and found no difference in survival and myocardial infarction between the two groups. However, the trial was conducted under the assumption that patients would be referred to the most efficacious revascularization therapy; it was apparent that CABG was underutilized in many appropriate patients in the ISCHEMIA trial. The study highlighted the importance of optimizing medical therapy in stable ischemic heart disease (SIHD) patients but does not answer whether revascularization or conservative management is better for patients with SIHD. SUMMARY: Optimal medical therapy is an important element and should be included in the Heart Team discussion, and also applied after revascularization from PCI or CABG. Cardiac surgeons need to continue to advocate for the appropriate use of CABG based on the current available evidence.

Identification and Evaluation of Controlled Trials in Pediatric Cardiology: Crowdsourced Scoping Review and Creation of Accessible Searchable Database.

Cardiac disease in children is associated with significant morbidity and mortality as well as increased health resource utilisation. There is a perception that there is a paucity of high-quality studies, particularly randomized controlled trials (RCTs), in the field of pediatric cardiology. We sought to identify, examine, and map the range of RCTs conducted in children with cardiac conditions, including the development of a searchable open-access database. A literature search was conducted encompassing MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to 2018. All English-language RCTs enrolling children (age 0-21 years) with cardiac conditions were included. Data extraction and risk of bias assessments were performed in duplicate via crowdsourcing for each eligible study and entered into an online database. A total of 933 RCTs met eligibility criteria. Median trial recruitment was 49 patients (interquartile range 30-86) with 18.9% of studies (n = 176) including > 100 patients. A wide variety of populations and interventions were encompassed with congenital heart disease (79.8% of RCTs) and medications (63.3% of RCTs) often studied. Just over one-half of the trials (53.4%) clearly identified a primary outcome, and fewer than half (46.6%) fully documented a robust randomization process. Trials were summarised in a searchable online database (https://pediatrics.knack.com/cardiology-rct-database#cardiology-rcts/). Contrary to a commonly held perception, there are nearly 1,000 published RCTs in pediatric cardiology. The open-access database created as part of this project provides a resource that facilitates an efficient comprehensive review of the literature for clinicians and researchers caring for children with cardiac issues.

Interleukin-6 Mediates Post-Infarct Repair by Cardiac Explant-Derived Stem Cells.

Although patient-sourced cardiac explant-derived stem cells (EDCs) provide an exogenous source of new cardiomyocytes post-myocardial infarction, poor long-term engraftment indicates that the benefits seen in clinical trials are likely paracrine-mediated. Of the numerous cytokines produced by EDCs, interleukin-6 (IL-6) is the most abundant; however, its role in cardiac repair is uncertain. In this study, a custom short-hairpin oligonucleotide lentivirus was used to knockdown IL-6 in human EDCs, revealing an unexpected pro-healing role for the cytokine. METHODS: EDCs were cultured from atrial appendages donated by patients undergoing clinically indicated cardiac surgery. The effects of lentiviral mediated knockdown of IL-6 was evaluated using in vitro and in vivo models of myocardial ischemia. RESULTS: Silencing IL-6 in EDCs abrogated much of the benefits conferred by cell transplantation and revealed that IL-6 prompts cardiac fibroblasts and macrophages to reduce myocardial scarring while increasing the generation of new cardiomyocytes and recruitment of blood stem cells. CONCLUSIONS: This study suggests that IL-6 plays a pivotal role in EDC-mediated cardiac repair and may provide a means of increasing cell-mediated repair of ischemic myocardium.