Restricted Cusp Motion in Newly Implanted Tricuspid Bioprostheses: Incidence, Predictors, and Impact on Survival.

OBJECTIVE: This study aimed to investigate the occurrence of restricted cusp motion (RCM) at the time of bioprosthetic tricuspid valve replacement (TVR) and analyzed associated risk factors and outcomes. METHODS: This study involved adult patients who underwent TVR with a bioprosthesis at our institution between 2012 and 2022. Bioprosthetic cusp motion was analyzed de-novo through a detailed review of intraoperative transesophageal echocardiograms (TEE). Two models of porcine valves were implanted, the Hancock II bioprosthesis (Medtronic, Inc, Minneapolis, Minnesota) and the St. Jude Epic bioprosthesis (St. Jude Medical, St. Paul, Minnesota). RESULTS: Among the 476 patients who met the inclusion criteria, RCM was identified on the immediate post-bypass TEE in 150 (31.5%); there was complete immobility of the cusp in 63 patients (13.2%) and limited movement of a cusp in 87 patients (18.3%). In a multivariable logistic regression analysis, the Hancock II model (OR 6.15, p<0.001), a larger orifice area (per IQR increase, OR 1.58, p=0.017), a smaller body surface area (per IQR increase, OR 0.68, p=0.040), and a lower ejection fraction (per IQR increase, OR 0.60, p=0.033) were independently associated with having RCM. Cox regression adjusting for 15 covariates revealed that RCM at time of TVR was independently associated with an increased risk of mortality (HR 1.35, p=0.049). CONCLUSIONS: This study revealed a high incidence of restricted cusp motion in bioprosthetic valves in the tricuspid position detected shortly post-implantation, which was associated with increased late mortality. To reduce the probability of restricted cusp motion, it is important to select the appropriate prosthesis model and size, particularly in small patients.

Simultaneous Tricuspid Valve Repair at the Time of Mitral Valve Surgery: Determinants of Postoperative Pacemaker Implantation.

OBJECTIVE: Guidelines recommend tricuspid valve (TV) repair for patients with severe tricuspid valve regurgitation (TR) undergoing surgery for degenerative mitral valve (MV) disease, but management of ≤ moderate TR is controversial. This study examines the incidence and causes of bradyarrhythmias leading to PPM implantation. METHODS: Review of patients undergoing simultaneous TV repair and MV surgery for degenerative MV disease from 2001 to 2022 (N=404). Primary endpoint was the incidence of postoperative PPM implantation. Secondary endpoints included the incidence of high-degree AV block and overall survival. RESULTS: All patients underwent TV repair at the time of MV surgery; 332 (82%) underwent MV repair and 72 (18%) MV replacement. Tricuspid valve repair techniques included flexible band (n=258, 63.8%), DeVega annuloplasty (n=78, 19.3%), complete flexible ring (n=49, 12.1%), and incomplete rigid ring (n=19, 4.7%). The 30-day mortality was 0.5% (n=2). A total of 35 (8.7%) patients had a PPM implanted postoperatively, 26 (6.4%) for high-degree AV block. On multivariable analysis, only older age was associated with PPM implantation. Patients who received a PPM due to high-degree AV block had reduced overall survival (Figure, p=0.01). CONCLUSIONS: Need for permanent pacing following TV repair at the time of MV surgery is not uncommon, but there are few modifiable factors that might reduce this risk. Careful selection of patients with less-than-severe TR and surgical techniques may reduce PPM-related risks and complications.

Outcomes of aortic surgery in patients with Takayasu arteritis.

OBJECTIVE: To investigate the presentation, aortic involvement, and surgical outcomes in patients with Takayasu arteritis undergoing aortic surgery. METHODS: We queried our surgical database for patients with Takayasu arteritis who underwent aortic surgery from 1994 to 2022. RESULTS: There were a total of 31 patients with Takayasu arteritis who underwent aortic surgery. Patients' median age at the time of diagnosis was 35.0 years (interquartile range, 25.0-42.0). The majority were female (n = 27, 87.0%). Most patients (n = 28, 90.3%) were diagnosed before surgery, and 3 patients (9.6%) were diagnosed perioperatively. The median time interval from diagnosis to surgery was 2.8 years (interquartile range, 0.5-13.9). The most common presentation was ascending aorta aneurysm (n = 22, 70.9%), and severe aortic regurgitation was the most common valve insufficiency (n = 17, 54.8%). The most common operation was ascending aorta replacement (n = 20, 64.5%), and aortic valve replacement was the most common valve intervention (n = 17, 54.8%). Active vasculitis was identified in 2 (11.7%) aortic valve specimens. Early mortality was 6.5% (n = 2). A total of 6 deaths occurred over a median follow-up of 13.1 years (interquartile range, 6.1-25.2). Survival at 10 years was 86.7% (95% CI, 75.4-99.7). A total of 5 patients (16.1%) required a subsequent operation in a median of 1.9 years (interquartile range, 0.2-7.4). Freedom from reoperation was 96.9% (95% CI, 90.1-100) at 1 year, 89.4% (95% CI, 78.7-100.0) at 5 years, and 77.5% (95% CI, 61.2-98.1) at 10 and 15 years. CONCLUSIONS: Ascending aorta aneurysm and aortic valve regurgitation are the most frequent presentations in patients with Takayasu arteritis requiring aortic surgery. Surgery in these individuals is safe, with acceptable short- and long-term results.

Life-Threatening Aortic Dissection during Pregnancy: A Case Report of Undiagnosed FBN1-Related Marfan Syndrome at 39 Weeks Gestation.

BACKGROUND Inherited deficiencies in the FBN1 gene, which encodes fibrillin-1, result in Marfan syndrome, an autosomal dominant connective tissue disorder that is associated with aortic root dilatation and predisposes to aortic dissection. This report is of a 37-year-old woman presenting at 39 weeks of pregnancy with acute thoracic aortic dissection due to previously undiagnosed FBN1-related Marfan syndrome. This case report aims to illustrate the challenges in the diagnosis and in the peri-operative management of acute aortic dissection during pregnancy. CASE REPORT A healthy 37-year-old woman at 39 weeks of gestation presented to our hospital with dyspnea and chest pain. Initial evaluation for pulmonary embolism with chest computed tomography was unrevealing. The patient was admitted to the intensive care unit for further management. Overnight, her clinical conditions deteriorated, and a transthoracic echocardiography was obtained, demonstrating an acute ascending aortic dissection. She emergently underwent a successful combined cesarean section and ascending aortic dissection repair, with no immediate complications. On postoperative day 4 she developed cardiac tamponade, for which she underwent emergent mediastinal exploration. She was discharged home on postoperative day 10. A month later she completed genetic testing, which revealed a pathogenic mutation in the FBN1 gene, consistent with a molecular diagnosis of Marfan syndrome. CONCLUSIONS This report has shown that FBN1-related Marfan's syndrome has a variable clinical presentation that can include life-threatening aortic dissection during pregnancy. Successful diagnosis and management of these patients is challenging and requires multidisciplinary expertise, including confirmation of the diagnosis by a clinical geneticist.

Whole Body Retrograde Perfusion Combined With Central Aortic Perfusion Strategy in the Repair of Distal Arch Pathology Through a Lateral Thoracotomy.

OBJECTIVE: To compare the results of the hypothermic circulatory arrest (HCA) + retrograde whole-body perfusion (RBP) technique with those of deep hypothermic circulatory arrest (DHCA-only) approach. METHODS: Limited data are available on cerebral protection techniques when distal arch repairs are performed through a lateral thoracotomy. In 2012, the RBP technique was introduced as adjunct to HCA during open distal arch repair via thoracotomy. We reviewed the results of the HCA + RBP technique compared with those of the DHCA-only approach. From February 2000 to November 2019, 189 patients (median age, 59 [IQR, 46 to 71] years; 30.7% female) underwent open distal arch repair via lateral thoracotomy to treat aortic aneurysms. The DHCA technique was used in 117 patients (62%, median age 53 [IQR, 41 to 60] years), whereas HCA + RBP was used in 72 patients (38%, median age 65 [IQR, 51 to 74] years). In HCA + RBP patients, cardiopulmonary bypass was interrupted when systemic cooling achieved isoelectric electroencephalogram; once the distal arch had been opened, RBP was then initiated via the venous cannula (flow of 700 to 1000 mL/min, central venous pressure <15 to 20 mm Hg). RESULTS: The stroke rate was significantly lower in the HCA + RBP group (3%, n=2) compared with the DHCA-only (12%, n=14) (P=.031), despite longer circulatory arrest times in HCA + RBP compared with the DHCA-only (31 [IQR, 25 to 40] minutes vs 22 [IQR, 17 to 30] minutes, respectively; P<.001). Operative mortality for patients undergoing HCA + RBP was 6.7% (n=4), whereas for those undergoing DHCA-only it was 10.4% (n=12) (P=.410). The 1-, 3-, and 5-year age-adjusted survival rates for the DHCA group are 86%, 81%, and 75%, respectively. The 1-, 3-, and 5-year age-adjusted survival rates for the HCA + RBP group are 88%, 88%, and 76%, respectively. CONCLUSION: The addition of RBP to HCA in the treatment of distal open arch repair via a lateral thoracotomy is safe and provides excellent neurological protection.

A midline retroperitoneal approach for complex abdominal aortic repair: Case description and operative technique.

In the current endovascular era, open repair of complex aortic aneurysms is becoming a rare, but indispensable, part of vascular surgeons' skill set in specific scenarios. For young, low-risk patients and patients with connective tissue disorders, early target vessel bifurcation, a horseshoe kidney, or pedunculated intraluminal aortic thrombus, fenestrated-branched stent graft technology will not be applicable without significant risks. Thus, an open surgical approach has been recommended for these patients. Most vascular surgeons will be familiar with a transperitoneal approach or a retroperitoneal approach with a lateral incision. For patients with a horseshoe kidney, an inflammatory aneurysm, or a history of multiple intraperitoneal procedures, a retroperitoneal approach should be preferred. In the present report, we have described in detail the optimization of a retroperitoneal approach through a midline incision that provides excellent exposure to the paravisceral aorta, improves exposure to the right renal artery and right iliac artery bifurcation (which is limited using the left flank retroperitoneal approach), and avoids division of the lateral abdominal wall muscles, which has often been associated with iatrogenic muscle denervation and postoperative bulging for four patients who had required complex aortic reconstruction.

Cannulation strategies for acute type A dissection-role of central cannulation.

OBJECTIVES: The purpose of this study was to assess the safety and efficacy of direct cannulation of the ascending aorta in comparison with cannulating peripheral arteries. METHODS: We retrospectively analysed type A dissection patients [n = 107; median (interquartile range [IQR]) age, 64 [53-73] years] from January 2008 to March 2018. The cohort was divided into 2 groups: direct ascending aorta cannulation (group A, n = 47; median [IQR] age, 69 [54-74] years; 34% female) and non-aortic cannulation (group B, n = 60; median [IQR] age, 62 [52-72] years; 20% female). Postoperative outcomes and long-term survival were compared. RESULTS: Baseline characteristics were not significantly different between the 2 groups, except for higher creatinine in group B (median 0.9 vs 1.1, P = 0.028) and higher prevalence of dyslipidaemia in group A (58.7% vs 38.3%, P = 0.037). Overall early mortality was 12.1% (n = 13); 12.8% (n = 6) in group A and 11.7% (n = 7) in group B (P = 0.863). The incidence of stroke was 10.6% (n = 5) in group A and 6.7% (n = 4) in group B (P = 0.463). After adjusting for CPB and circulatory arrest times, there was no group difference in the length of ICU (P = 0.257) or hospital stay (P = 0.118), all-cause reoperation (P = 0.709), peak postoperative creatinine (P = 0.426) and lactate values (n = 60; P = 0.862). Overall survival at 1, 3 and 5 years was 84%, 78% and 73%, respectively, with no difference between the 2 groups after adjustment (P = 0.629). CONCLUSIONS: Direct cannulation of the ascending aorta is a safe cannulation strategy for type A dissection repair, offering the opportunity for rapid arterial cannulation and antegrade perfusion.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes.

OBJECTIVES: There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes. METHODS: We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients. RESULTS: The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time. CONCLUSIONS: Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Outcomes of Tricuspid Valve Repair With Artificial Neochordae in Pediatric and Adult Patients.

BACKGROUND: There are sparse data on outcomes after expanded polytetrafluoroethylene artificial neochordae (ePTFE-AN) for tricuspid valve (TV) repair. We evaluated outcomes after TV repair with ePTFE-AN in both pediatric and adult patients. METHODS: We analyzed clinical data of 87 consecutive patients who underwent ePTFE-AN implantation at the time of TV repair from 1998 to 2020. Patients were categorized into pediatric and adult groups. RESULTS: There were 29 pediatric (33.3%) and 58 adult (66.7%) patients. The most common etiology of tricuspid regurgitation (TR) was congenital (pediatrics: 86.2% [25 of 29]; adults: 39.7% [23 of 59]). The median number of pairs of ePTFE-AN implanted was 2 (interquartile range [IQR], 2-5 pairs) for pediatric and 3 (IQR, 2-4 pairs) for adult patients. There was no early death. Three adult patients (5.2%) required early TV reoperation, and 4 patients (1 pediatric, 3 adults) underwent late TV reintervention. Etiology of TR was congenital in 4 of the 6 adults who required TV reintervention. The 3-year cumulative risk of TV reintervention was 0.0% for pediatric and 7.3% (95% CI, 0.4%-14.2%) for adult patients. There was significant improvement in TR grade after TV repair at dismissal and at the latest echocardiographic follow-up in each group (P < .001). Severe TR developed in 1 pediatric patient and 7 adult patients during follow-up, and 6 (1 pediatric, 5 adults) of them underwent TV reoperation. CONCLUSIONS: ePTFE-AN implantation in the TV position can be performed safely and effectively with no early death. In adult patients with congenital TR, patient selection is critical to achieve a durable outcome after TV repair.

Outcomes and risk factors of late failure of valve-sparing aortic root replacement.

OBJECTIVE: Retention of the native aortic valve when performing aortic root surgery for aneurysmal disease has become a more common priority. We reviewed our experience in valve-sparing aortic root replacement (VSARR) to evaluate the long-term outcomes and the risk factors for reoperation. METHODS: From January 1994 through June 2017, 342 patients (mean age 47.8 ± 15.5 years, 253 [74%] male) underwent VSARR. The most common etiologies were connective tissue disease (n = 143, 42%) followed by degenerative aortic aneurysm (n = 131, 38%). Aortic regurgitation (moderate or greater) was present in 35% (n = 119). RESULTS: Reimplantation technique was used in 90% patients (n = 308). Valsalva graft was used in 38% patients (n = 131) and additional cusp repair was done in 15% (n = 50). Operative mortality was 1% (n = 5). The median follow-up time was 8.79 years (interquartile range, 4.08-13.51). The cumulative incidence of reoperation (while accounting for the competing risk of death) was 8.4%, 12.8%, and 17.1% at 5, 10, and 15 years, respectively. There were no differences in survival and incidence of reoperation between root reimplantation and remodeling. Larger preoperative annulus diameter was associated with greater risk of reoperation (hazard ratio, 1.10; 95% confidence interval, 1.02-1.19, P = .01). The estimated probability of developing severe aortic regurgitation after VSARR was 8% at 10 years postoperatively. Operative mortality, residual aortic regurgitation at dismissal, and survival improved in recent times with more experience. CONCLUSIONS: VSARR is a viable and safe option with good long-term outcomes and low rates of late aortic valve replacement. Dilated annulus preoperatively was associated with early repair failure.

Natural History and Outcomes of Nonreplaced Aortic Sinuses in Patients With Bicuspid Aortic Valves.

BACKGROUND: Enlargement of the sinus of Valsalva (SOV) is common in patients with bicuspid aortic valves (BAVs), and management at the time of aortic valve replacement (AVR) and concomitant ascending aorta replacement/repair is controversial. METHODS: Between January 2000 and July 2017, 400 patients with BAVs underwent AVR and concomitant ascending aorta repair (graft replacement, 79%; aortoplasty, 21%). To assess the impact of the initial SOV dimension on future dilatation and outcomes, patients were stratified into 2 groups: SOV of less than 40 mm (SOV<40 mm) (n = 209) and SOV of 40 mm or larger (SOV≥40 mm) (n = 191). RESULTS: Patients with SOV≥40 mm were older and more often male. At a median follow-up of 8.1 years (interquartile range, 7.4-9.1 years), 6 patients underwent reoperations on the ascending or sinus portion of the aorta due to aneurysmal dilatation, and enlargement of the sinus was the primary indication for operation in 1 patient. Adjusted analysis showed that baseline SOV and SOV dimension over time were not associated with late outcomes. A gradual increase in SOV diameter over time was identified (P = .004). Patients with smaller baseline SOV diameters showed an initial early decrease in diameter, followed by gradual increase, whereas those with larger baseline diameters had a stable early phase, followed by gradual dilatation. CONCLUSIONS: Ascending aorta replacement may lead to an initial remodeling/stabilizing effect on the spared bicuspid aortic root, which is more pronounced in patients with lower SOV diameters. In addition, our data demonstrate that the retained aortic sinuses enlarge slowly, and within the limited follow-up of our study, SOV diameter was not a risk factor for survival or reoperation.

Outcomes and Echocardiographic Follow-up After Surgical Management of Tricuspid Regurgitation in Patients With Transvenous Right Ventricular Leads.

OBJECTIVE: To evaluate outcomes of elective surgical management of tricuspid regurgitation (TR) in patients with transvenous right ventricular leads, and compare results between non-lead-induced and lead-induced TR patients. PATIENTS AND METHODS: We studied patients with right ventricular leads who underwent tricuspid valve surgery from January 1, 1993, through December 31, 2015, and categorized them as non-lead-induced and lead-induced TR. Propensity score (PS) for the tendency to have lead-induced TR was estimated from logistic regression and was used to adjust for group differences. RESULTS: From the initial cohort of 470 patients, 444 were included in PS-adjustment analyses (174 non-lead-induced TRs [123 repairs, 51 replacements], 270 lead-induced TRs [129 repairs, 141 replacements]). In PS-adjusted multivariable analysis, lead-induced TR was not associated with mortality (P=.73), but tricuspid valve replacement was (hazard ratio, 1.59; 95% CI, 1.13 to 2.25; P=.008). Five-year freedom from tricuspid valve re-intervention was 100% for non-lead-induced TR and 92.3% for lead-induced TR; rates adjusted for PS differed between groups (P=.005). There was significant improvement in TR postoperatively in each group (P<.001). In patients having tricuspid valve repair, TR grades tended to worsen over time, but the difference in trends was not significantly different between groups. CONCLUSION: Lead-induced TR did not affect long-term survival after elective tricuspid valve surgery. In patients with lead-induced TR, tricuspid valve re-intervention was more common. Improvement in TR was achieved in both groups after surgery; however, severity of TR tended to increase over follow-up after tricuspid valve repair.

Management of Coarctation and Aortic Arch Anomalies in the Adult.

Congenital Aortic arch malformations are rare in adults. Often they present with hypertension or tracheoesophageal compression. The involved anatomy is dependent on the sidedness of the aortic arch and the variable development of the primitive pharyngeal arches. Sternotomy and thoracotomy are usually required for surgical repair, while need for circulatory arrest is not uncommon. With caution and adequate planning, surgery can be carried out with satisfactory results.

Cannulation strategies & circulation management in type-A aortic dissection.

Type A aortic dissection most often requires emergent surgery to prevent malperfusion, stroke, and/or rupture of aorta. To achieve the structural goals of the operation, the conduct of the surgery is targeted from it inception at restoring true lumen flow. In this regard, institution of cardiopulmonary bypass and circulation management is key to allow adequate systemic flow, perfusion of brain and visceral organs and comprehensive systemic cooling to achieve circulatory arrest when needed. Different strategies have been used to establish adequate true lumen perfusion with varying success rates, with the most common still being femoral cannulation. More recently axillary and central cannulation strategies have shown satisfactory results by allowing more reliable true lumen flow. Cannulation approach should, therefore, depend on individual patient characteristics, presentation, and true lumen anatomy.

Bicuspid Aortic Valve Repair: Causes of Valve Failure and Long-Term Outcomes.

BACKGROUND: Repair of bicuspid aortic valves (BAVs) for aortic regurgitation (AR) has favorable outcomes, but the impact of natural disease progression on durability of repair is uncertain. We evaluated causes of reoperation and compared outcomes of BAV repair to those of patients undergoing aortic valve replacement (AVR). METHODS: Between January 1993 and December 2016, 113 patients had BAV repair at our institution for significant AR. Operative notes and pathology reports were studied to identify late causes of repair failure. For comparison with AVR, we utilized propensity score weighting with the score derived from preoperative and operative characteristics using gradient boosting machine model. RESULTS: A total of 26 patients had late AVR after initial repair. Causes of late valve dysfunction included calcification or fibrosis of the cusps (68%), concomitant replacement addressing moderate degree of aortic valve disease to avoid future operation (20%), and cusp prolapse (12%). Pathological evaluation of these excised valves reported calcification and fibrosis in 88% of the valves. Ten-year survival of patients undergoing BAV repair was 91% compared with 90% for patients undergoing AVR with a mechanical valve and 79% for AVR with a bioprosthesis (P = .6). Incidence of reoperation after AVR with a bioprosthesis was similar to risk after repair whereas AVR with mechanical valve showed significant advantage. CONCLUSIONS: Disease progression with calcification or fibrosis is the most common cause of valve failure after initial repair of BAV. Clinical outcomes of BAV repair for severe AR appear superior to AVR with bioprosthesis.

Repair of Partial Atrioventricular Septal Defects in Adults: A Single Center Experience.

Limited data are available on long-term outcome after repair of partial atrioventricular septal defects (pAVSD) in adults. We sought to review our experience. Between January 1, 1957 and December 31, 2016, 179 adult patients [median age (IQR) 34 (18, 72) years] underwent primary repair of pAVSD. The most common associated defects were secundum atrial septal defect (n = 38) and ventricular septal defect (VSD) (n = 7). Left atrioventricular valve (LAVV) zone of apposition (ZOA) was complete in 47 patients and LAVV regurgitation (≥moderate) was present in 73 patients. Autologous pericardium (n = 79, 45%) and polytetrafluoroethylene felt (n = 56, 32%) were mainly used for pAVSD closure.  Repair techniques for LAVV regurgitation included: ZOA suture closure (n =  142), suture annuloplasty (n = 10) and posterior band annuloplasty (n = 9). Six had LAVV replacement. There were 61 deaths over a median follow-up of 21 years (IQR 10, 38), with only 4 early deaths. In a limited subset of patients with 80 paired measurements (n = 40), median right ventricular systolic pressure declined from 43 mm Hg (IQR 35-51) to 33 mm Hg (IQR 30-44) postoperatively (P < 0.001), and this improvement was sustained over long-term follow-up (P = 0.513). A total of 34 patients underwent a reoperation (recurrent LAVV regurgitation, n = 26; left ventricular outflow-tract obstruction, n = 7; LAVV stenosis, n = 4; patch dehiscence, n = 1) with cumulative incidence of 6% and 16% at 10 and 15 years, respectively. Repair of pAVSD in adults can be done safely with low early mortality and good long-term outcomes. Postrepair reduction of pulmonary artery pressure is significant. Despite the low re-operation rates, long-term surveillance remains essential.

Central Partial Bypass Management Technique for Distal Arch Surgery.

Circulatory arrest and left heart bypass are the most common approaches to manage perfusion during distal arch surgery. We report a novel perfusion technique utilized in the treatment of aneurysmal Komerrell's diverticulum (KD) and aberrant subclavian artery (ASA) that allows for a reliable conduct of perfusion. From 2016 to 2020, 12 adult patients with aneurysmal KD and ASA underwent repair of distal arch through lateral thoracotomy ipsilateral to the arch side using central partial bypass. Once the patients were fully heparinized the lower thoracic aorta and the right atrium were cannulated. The cannulas were connected to the cardiopulmonary bypass (CPB) circuit with an oxygenator. Partial bypass was initiated. Ventilation via anesthesia was continued as the mode of gas exchange to the upper body while the CPB circuit provided gas exchange to the lower body. In all patients, CPB was initiated allowing the patient to maintain a mean arterial pressure >60 mmHg in the femoral artery and a mean arterial pressure (MAP) >80 mmHg in the radial artery to allow adequate native ejection into the proximal circulation. The venous line was partially occluded to control the radial pressure. The aorta was cross clamped proximal and distal to the KD to isolate the aorta to be replaced. KD was excised in all patients having performed contralateral subclavian to carotid transposition previously. Once the aorta was reconstructed, clamps were released and the patients were weaned off CPB. All were extubated on the same day and there was no early mortality.

Outcomes of tricuspid valve surgery in patients with functional tricuspid regurgitation.

OBJECTIVES: Functional tricuspid regurgitation (fTR) has been amenable to tricuspid valve repair (TVr), with fewer patients needing tricuspid valve replacement (TVR). We sought to review our experience of tricuspid valve surgery for fTR. METHODS: A retrospective analysis of adult patients (≥18 years) who underwent primary tricuspid valve surgery for fTR (n = 926; mean age 68.6 ± 12.5 years; 67% females) from January 1993 through June 2018 was conducted. There were 767 (83%) patients who underwent TVr (ring annuloplasty, 67%; purse-string annuloplasty, 33%) and 159 (17%) underwent TVR (bioprosthetic valves, 87%; mechanical valves, 13%). The median follow-up was 8.2 years [95% confidence interval (CI) 7.2-8.9 years]. RESULTS: A greater proportion of patients who underwent TVR had severe right ventricular dysfunction (P < 0.001), severe tricuspid regurgitation (P < 0.001) and congestive heart failure (P = 0.001) while the TVr cohort had a greater proportion with severe mitral valve (MV) regurgitation (P < 0.001) and concomitant cardiac procedures. Early mortality (TVR, 9% vs TVr, 3%; P = 0.004), renal failure (TVR, 10% vs TVr, 5%; P = 0.014) and hospital stay (TVR, 15 ± 15 days vs TVr, 12 ± 11 days; P < 0.001) were greater in TVR patients. The TVR cohort had worse survival [hazard ratio (HR) 1.57; 95% CI 1.23-1.99]. Multivariable analysis identified congestive heart failure (HR 1.37; 95% CI 1.10-1.72), renal failure (HR 1.79; 95% CI 1.14-2.82), previous MV surgery (HR 1.35; 95% CI 1.05-1.72) and TVR (HR 1.36; 95% CI 1.03-1.79) as independent risk factors for late mortality. CONCLUSIONS: Tricuspid repair for fTR appears to have better early and late outcomes. Since previous MV surgery and TVR are identified as independent risk factors for late mortality, concomitant TVr at the time of index MV surgery may be considered. Early referral before the onset of advanced heart failure may improve outcomes.