Surgical Management of Heart Failure.

Optimal management of heart failure is collaborative, with the involvement of specialist heart failure physicians, nurses, interventionalists, and surgeons. In addition to medical optimisation and cardiac resynchronisation therapy, surgery plays a valuable role in many patients. We herein study the evidence and the role of surgical intervention in functional mitral regurgitation, coronary revascularisation in ischaemic cardiomyopathy, and surgical ventricular reconstruction. Additionally, we describe techniques of temporary and durable mechanical circulatory support, with their relative advantages and disadvantages, and applications. Finally, we describe the history and nomenclature around heart transplants, their indications, techniques, present-day outcomes, complications, and new developments in the field.

Mitral valve repair rates in degenerative mitral valve disease correlate with surgeon and hospital procedural volume.

STUDY AIM: To determine the relationship between surgeon and hospital procedural volume, and mitral valve repair rates and 30-day mortality for degenerative mitral regurgitation (MR), in Australian cardiac surgical centers. METHODS: A total of 4420 patients who underwent elective surgery for degenerative MR between January 2008 and December 2017 in the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database were retrospectively included. Univariate and multivariate regression analyses examined surgeon and hospital procedural volumes for associations with repair rate and mortality. RESULTS: Repair rates varied widely by caseload; from 62.57% to 79.53% for lowest to highest volume surgeons; and from 54.56% to 77.54% for lowest to highest volume hospitals. Compared to surgeons performing ≤5 procedures/annum, surgeons performing 10.1-20/annum were more likely to repair the valve (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.09-5.28, p = .03), particularly if performing more than 20/annum (OR 2.88, 95% CI 1.09-7.60, p = .03). Compared to hospitals performing ≤10/annum, those performing any number of procedures more than 10 demonstrated an increased likelihood of repair (caseload 10.1-20/year OR 1.96, 95% CI 1.25-3.07, p = .003) though odds did not increase above this threshold. Low incidence of 30-day mortality (63 of 4414, 1.43%) limited analysis of contributing variables; procedural volume did not confer a survival benefit. CONCLUSIONS: Surgeon and hospital caseload were significantly associated with repair rates of degenerative MR. A threshold minimum of 10 procedures annually for surgeons and hospitals should be utilized to maximize repair rates, and ideally of 20 for surgeons. Mortality was low and may not be significantly impacted by procedural volume.

Fresh arterial homograft for bypass in critical limb ischaemia with infection.

We present what we believe is Australia's first fresh peripheral arterial transplant for revascularisation of an ischaemic limb. Although cryopreserved homografts are accepted as a management option for revascularisation of critical limb ischaemia in infected fields, cryopreserved peripheral vascular tissue is not currently available in Australia. We describe a 72-year-old man without autologous conduit in whom infected prosthetic grafts were explanted, causing critical limb ischaemia of a below knee stump. Fresh peripheral arterial tissue was procured via the Australian organ donation authority, DonateLife, and was used to revascularise the stump with an axillofemoral bypass. This permitted successful healing of the stump within 6 weeks and mobilisation with a prosthesis. This case illustrates that fresh arterial homografts are a viable bridging solution for revascularisation of limb ischaemia with infection. However, it also highlights the need to establish a peripheral homograft bank so that cryopreserved conduits are readily available for similar scenarios.