Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure: A Post Hoc Analysis of a Randomized Clinical Trial.

Importance: The Ross procedure as treatment for adults with aortic valve disease (AVD) has been the subject of renewed interest. Objective: To evaluate the long-term clinical and echocardiographic outcomes following the Ross procedure for the treatment of adults with AVD. Design, Setting, and Participants: This post hoc analysis of a randomized clinical trial included adult patients (age <69 years) who underwent a Ross procedure for the treatment of AVD, including those with active endocarditis, rheumatic AVD, decreased ejection fraction, and previous cardiac surgery. The trial, conducted from September 1, 1994, to May 31, 2001, compared homograft root replacement with the Ross procedure at a single center. Data after 2010 were collected retrospectively in November and December 2022. Exposure: Ross procedure. Main Outcomes and Measures: The primary end point was long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin- and sex-matched general population. Secondary end points were freedom from any reintervention, autograft reintervention, or homograft reintervention and time-related valve function, autograft diameter, and functional status. Results: This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%). Conclusions and Relevance: This study found that the Ross procedure provided excellent survival into the third decade postoperatively that was comparable to that in the general population. Long-term freedom from reintervention demonstrated that the Ross procedure may be a durable substitute into late adulthood, showing a delayed but progressive functional decline. Trial Registration: isrctn.org Identifier: ISRCTN03530985.

Multidisciplinary paper on patient blood management in cardiothoracic surgery in the UK: perspectives on practice during COVID-19.

The coronavirus (COVID-19) pandemic disrupted all surgical specialties significantly and exerted additional pressures on the overburdened United Kingdom (UK) National Health Service. Healthcare professionals in the UK have had to adapt their practice. In particular, surgeons have faced organisational and technical challenges treating patients who carried higher risks, were more urgent and could not wait for prehabilitation or optimisation before their intervention. Furthermore, there were implications for blood transfusion with uncertain patterns of demand, reductions in donations and loss of crucial staff because of sickness and public health restrictions. Previous guidelines have attempted to address the control of bleeding and its consequences after cardiothoracic surgery, but there have been no targeted recommendations in light of the recent COVID-19 challenges. In this context, and with a focus on the perioperative period, an expert multidisciplinary Task Force reviewed the impact of bleeding in cardiothoracic surgery, explored different aspects of patient blood management with a focus on the use of haemostats as adjuncts to conventional surgical techniques and proposed best practice recommendations in the UK.

The results of cardiac surgery during the COVID-19 pandemic compared with previous years: a propensity weighted study of outcomes at six months.

OBJECTIVES: In addition to excess mortality due to COVID-19, the pandemic has been characterised by excess mortality due to non-COVID diagnoses and consistent reports of patients delaying seeking medical treatment. This study seeks to compare the outcomes of cardiac surgery during and before the COVID-19 pandemic. DESIGN: Our institutional database was interrogated retrospectively to identify all patients undergoing one of three index procedures during the first six months of the pandemic and the corresponding epochs of the previous five years. SETTING: A regional cardiothoracic centre. PARTICIPANTS: All patients undergoing surgery during weeks #13-37, 2015-2020. MAIN OUTCOME MEASURES: Propensity score weighted analysis was employed to compare the incidence of major complications (stroke, renal failure, re-ventilation), 30-day mortality, six month survival and length of hospital stay between the two groups. RESULTS: There was no difference in 30-day mortality (HR = 0.76 [95% CI 0.27-2.20], p = 0.6211), 6-month survival (HR = 0.94 [95% CI 0.44-2.01], p = 0.8809) and duration of stay (SHR = 1.00 (95% CI 0.90-1.12), p = 0.959) between the two eras. There were no differences in the incidence of major complications (weighted chi-square test: renal failure: p = 0.923, stroke: p = 0.991, new respiratory failure: p = 0.856). CONCLUSIONS: Cardiac surgery is as safe now as in the previous five years. Concerns over the transmission of COVID-19 in hospital are understandable but patients should be encouraged not to delay seeking medical attention. All involved in healthcare and the wider public should be reassured by these findings.

Long-term survival after xenograft versus homograft aortic root replacement: Results from a prospective randomized trial.

OBJECTIVE: The study objective was to investigate the long-term survival of patients undergoing xenograft versus homograft full root aortic valve replacement. METHODS: A total of 166 patients requiring aortic valve surgery were randomized to undergo the Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis (N = 90) or a homograft (N = 76) full root aortic valve replacement between 1997 and 2005 in a single institution. Six patients randomly assigned to the homograft crossed over to the Freestyle bioprosthesis because of the unavailability of suitably sized homografts. All surgeons were required to adhere to the standard surgical technique for homograft root implantation previously described. Follow-up was 98.5% complete. RESULTS: The mean age of the study population was 65 ± 8 years. Coronary artery bypass grafting was associated with root aortic valve replacement in 76 of 166 patients (46%, P = not significant between groups), and overall hospital mortality was 4.8% (8/166, P = not significant between groups). Median follow-up was 13.8 years (range, 0-21.8 years; 2033 patient-years). The Kaplan-Meier survival analysis showed that there was no significant difference in overall survival between the 2 arms at 5, 10, and 15 years. Twenty-year survival was 28.3% ± 5% for the Freestyle group versus 25.1% ± 5.7% for the homograft group (P = .90), which was comparable to the age- and sex-matched UK general population. The freedom from aortic valve reoperation at 20 years was comparable for the Freestyle group versus the homograft group (67.9% ± 8.8% vs 67.2% ± 10.3%, respectively; P = .74). CONCLUSIONS: This is the first study to investigate the long-term survival of xenograft versus homograft full root aortic valve replacement from a prospective randomized trial. The observed 20-year overall survival and freedom from aortic valve reoperation serve as a benchmark for future studies on interventions for aortic valve disease in the elderly.

A Rare and Late Complication After Left Ventricular Assist Device Explantation.

Late complications can arise after explantation of a left ventricular assist device. We report the case of a patient who presented at the age of 19 years with peri-partum cardiomyopathy and was initially managed with a biventricular support device, which was subsequently upgraded to an ambulatory left ventricular assist device. This was successfully explanted after myocardial recovery via a minimally invasive approach 7 months later. The patient re-presented 5 years following explantation with hemoptysis. At redo sternotomy, a 10-cm remnant of the outflow graft was found to be eroding the surface of the right lung. The conduit was excised and the stump oversewn. Eleven months later, she presented again with hemoptysis, and a pseudo-aneurysm was identified on the computed tomography scan. She underwent urgent open repair with peripheral cannulation and deep hypothermic total circulatory arrest. The Dacron stump was found to be partially dehisced, leaving a 2-3 cm defect in the ascending aorta. The defect was repaired with a bovine pericardial patch. The patient made a good recovery and was successfully discharged.

Survival probability loss from percutaneous coronary intervention compared with coronary artery bypass grafting across age groups.

BACKGROUND: Whether the survival benefit from coronary artery bypass grafting (CABG), compared with percutaneous coronary intervention (PCI), for multivessel disease extends to the older segment of the population remains unclear. We aimed to investigate whether the effect on survival of PCI compared with CABG is related to the age of the patient. METHODS: Propensity score-matching analysis was conducted on 6723 patients (PCI = 1097, CABG = 5626) with multivessel coronary artery disease. In the PCI group, drug-eluting stents were used in 917 (83.5%) patients; bare metal stents were used in only 180 patients (16.5%). Nonparametric, bootstrap, point-wise confidence limits were obtained for PCI:CABG odds and hazard ratios for early (within 12 months) and late hazard phase (beyond 12 months) for a variety of age groups. RESULTS: After a mean follow-up time of 5.5 ± 3.2 years, a total of 301 deaths were recorded in the matched sample (208 in the PCI group and 93 in the CABG group). Overall survival was 95% ± 0.6% versus 95% ± 0.6% at 1 year, 84% ± 1.0% versus 92.4% ± 0.8% at 5 years, and 75% ± 1.6% versus 90% ± 1.0% at 8 years, for the PCI and CABG groups, respectively (log rank P < .001). PCI did not confer any significant benefit compared with CABG during the early hazard phase (within 12 months), but the survival-probability loss from PCI compared with CABG during the late hazard phase was present across all age groups. The hazard ratio declined from 3.8 to 3.4 and was statistically significant (lower limit >1 across all ages, ranging from 1.5 to 2.4). CONCLUSIONS: Compared with PCI, CABG leads to a significant reduction in late-phase mortality across all age groups.

Right internal mammary artery versus radial artery as second arterial conduit in coronary artery bypass grafting: a case-control study of 1526 patients.

OBJECTIVE: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG. METHODS: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001-2013) was conducted to investigate the impact of the two strategies on early and late outcomes. RESULTS: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2-3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0-2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1-9.7) and obese patients (HR 2.1; 95% CI 0.8-5.46). CONCLUSIONS: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.

The influence of bilateral internal mammary arteries on short- and long-term outcomes: a propensity score matching in accordance with current recommendations.

OBJECTIVES: We undertook a single-center, 12 years outcomes analysis of the influence of bilateral internal mammary arteries (BIMA) over single internal mammary artery (SIMA) on short-term outcomes and long-term outcomes by means of propensity score matching technique in accordance to current recommendations. METHODS: A propensity score was generated for each patient from a multivariable logistic regression model based on 20 pretreatment covariates. The study population consisted of 4195 patients undergoing coronary artery bypass graft procedure using SIMA (n = 3445; 78.3%) or BIMA (n = 750; 21.7%). A total of 750 matching sets were derived. RESULTS: The BIMA group was associated with an increased rate of superficial sternal wound infection (5.6% vs 1.7%; P = .0001) but the incidence of deep sternal wound infection was comparable between the 2 groups, at 2.1% and 1.5% in BIMA and SIMA groups, respectively (P = .43). With regard to other postoperative complications the 2 groups were comparable. Operative mortality rate did not significantly differ between the 2 groups, at 0.7% and 1.2% in the BIMA and SIMA groups, respectively (P = .28). After a mean follow-up time of 4.8 ± 3.2 years, BIMA use was associated with a significantly lower risk for late mortality (hazard ratio, 0.61; 95% confidence interval 0.38-0.97; P = .03) and need for repeat revascularization (hazard ratio, 0.75; 95% confidence interval, 0.53-0.96; P = .03). CONCLUSIONS: When compared with SIMA grafting, BIMA use did not increase operative morbidity and mortality and was associated with a better long-term survival.

Predictors of survival after gastrointestinal complications in bypass grafting.

Between April 2001 and December 2005, data were collected prospectively from 2,320 consecutive patients who underwent first-time coronary artery bypass. Logistic multiple regression analyses were carried out to determine the independent predictors of gastrointestinal complications and death. There were 65 major gastrointestinal complications identified in 65 (2.8%) patients: paralytic ileus in 15, mesenteric ischemia in 12, upper gastrointestinal hemorrhage in 16, lower gastrointestinal hemorrhage in 8, small bowel obstruction in 5, pseudoobstruction in 5, and others in 4. The 30-day mortality was 21.5% (14 patients). Female sex, preoperative creatinine >200 µmol·L(-1), previous gastrointestinal pathology, low cardiac output, readmission to the intensive care unit, postoperative pulmonary complications, arrhythmias, hemofiltration, and reoperation were independent predictors of major gastrointestinal complications. Independent risk factors for death were readmission to the intensive care unit, the need for hemofiltration, reoperation, and ischemic bowel. Careful hemodynamic control and optimization of perioperative organ perfusion are important to minimize the mortality associated with major gastrointestinal complications after coronary artery bypass.

Ruptured sinus of Valsalva aneurysm presenting as ST-elevation myocardial infarction.

BACKGROUND: A 52-year-old man presented with central chest pain, which he had experienced for 8 h. He had no other associated symptoms and no prior history of cardiovascular disease. INVESTIGATIONS: Electrocardiography, chest radiography, coronary angiography, aortic angiography, echocardiography, CT thorax with contrast. DIAGNOSIS: Ruptured aneurysm of the sinus of Valsalva. MANAGEMENT: Emergency sternotomy and pericardiotomy, followed by aortic root replacement.

Does perioperative administration of thyroid hormones improve outcome following coronary artery bypass grafting?

The question addressed in this review is whether supplementation with thyroid hormones during the perioperative period improves the outcome of patients undergoing coronary artery bypass surgery. Altogether 88 relevant papers were identified using the below mentioned search, seven papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that although widespread interest has been shown on the use of thyroid hormones in the perioperative period, and the effect of cardiopulmonary bypass on thyroid hormone metabolism widely studied, there is no substantial evidence to justify routine use of thyroid hormones in patients undergoing coronary artery bypass grafting.

Propensity score analysis of early and late outcome after redo off-pump and on-pump coronary artery bypass grafting.

BACKGROUND: The purpose of this study was to compare early and late results of redo-CABG with (redo-ONCAB) and without (redo-OPCAB) cardiopulmonary bypass. METHODS: From April 2001 to September 2006 redo-CABG was performed in 110 patients (redo-ONCAB=50 and redo-OPCAB=60). Applying the propensity score, 43 OPCAB patients were matched with 43 ONCAB patients. The mean EuroScore was 5+/-4.7 and 5+/-3.4 for redo-ONCAB and redo-OPCAB, respectively (p=0.5). The number of diseased coronary arteries was 3+/-0.5 and 2+/-0.8 in redo-ONCAB and redo-OPCAB, respectively (p<0.01). RESULTS: Twelve patients underwent OPCAB through anterior thoracotomy while the rest of the patients (n=74) underwent median sternotomy. Mean number of grafts performed was 3+/-0.8 in redo-ONCAB and 2+/-0.6 in redo-OPCAB (p<0.05). The need for postoperative insertion of intra-aortic balloon pump (IABP) was higher (p=0.02) in redo-ONCAB (n=9, 21%) than redo-OPCAB (n=1, 2%). The duration of postoperative ventilation was 55+/-98.7 h for redo-ONCAB and 10+/-12.8h for redo-OPCAB (p=0.008). No differences were found in the incidence of other postoperative complications. The 30-day mortality rate was 6.9% for redo-ONCAB (n=3) and 2.3% redo-OPCAB (n=1; p=NS). Mean follow-up for redo-ONCAB was 30+/-21.3 months (range 0.1-63 months) and that of redo-OPCAB was 37+/-19.2 months (0.1-62.5 months). Actuarial survival at 5 years was 87+/-5.5% for redo-ONCAB and 95+/-3.2% for redo-OPCAB (p=0.17). Event-free survival was 71+/-8.0% for redo-ONCAB and 78+/-7.2% for redo-OPCAB (p=0.32). CONCLUSION: OPCAB is an acceptable strategy in selected patients requiring redo-CABG. Employing a strategy of OPCAB for those patients with 2 or fewer lesions and ONCAB for those with more diffuse disease, redo-OPCAB and redo-ONCAB have similar early and late outcomes.

Non-anastomotic avulsion of a left internal mammary artery graft--a rare complication of minimally invasive direct coronary artery bypass surgery.

OBJECTIVE: To describe a rare complication of minimally invasive coronary artery bypass surgery. METHOD: Case report. RESULTS: We present a 72-year-old patient with a left anterior descending artery stenosis who underwent elective minimally invasive direct coronary artery bypass (MIDCAB) surgery. Three months post-operatively he developed an anterior chest wall haematoma with electrocardiographic and enzyme evidence of myocardial ischaemia, though without haemodynamic embarrassment. Surgical exploration revealed non-anastomotic avulsion of the LIMA graft, which was bleeding freely into the left hemithorax. CONCLUSIONS: Minimally invasive direct coronary artery bypass surgery is now widely practised. Post-operative interruption of the left internal mammary artery graft is uncommon and avulsion of the graft proximal to the anastomosis with the left anterior descending artery has only been described in the literature on three occasions. This complication has been reported once in the setting of conventional bypass surgery and twice in the setting of minimally invasive direct coronary artery bypass surgery. In all of these cases, abrupt graft failure resulted in significant haemodynamic and/or ischaemic compromise, and all occurred within two weeks of surgery. Clinicians should be reminded of this rare though potentially catastrophic complication of MIDCAB surgery.

Randomized comparison of stentless versus stented valves for aortic stenosis: effects on left ventricular mass.

BACKGROUND: Aortic valve replacement (AVR) is the established treatment for severe aortic stenosis. In response to the long-term results of aortic homografts, stentless porcine valves were introduced as an alternative low-resistance valve. We conducted a randomized trial comparing a stentless with a stented porcine valve in adults with severe aortic stenosis. METHODS AND RESULTS: The primary outcome was change in left ventricular mass index (LVMI) measured by transthoracic echocardiography and, in a subset, by cardiovascular MR. Measurements were taken before valve replacement and at 6 and 12 months. Patients undergoing AVR with an aortic annulus < or =25 mm in diameter were randomly allocated to a stentless (n=93) or a stented supra-annular (n=97) valve. There were no significant differences in mean LVMI between the stentless versus stented groups at baseline (176+/-62 and 182+/-63 g/m2, respectively) or at 6 months (142+/-49 and 131+/-45 g/m2, respectively), although within-group changes from baseline to 6 months were highly significant. Changes in LVMI measured by cardiovascular MR (n=38) were consistent with the echo findings. There was a greater reduction in peak aortic velocity (P<0.001) and a greater increase in indexed effective orifice area (P<0.001) in the stentless group than in the stented group. There were no differences in clinical outcomes between the 2 valve groups. CONCLUSIONS: Despite significant differences in indexed effective orifice area and peak flow velocity in favor of the stentless valve, there were similar reductions in left ventricular mass at 6 months with both stented and stentless valves, which persisted at 12 months.

Mid-term pattern of survival, hemodynamic performance and rate of complications after medtronic freestyle versus homograft full aortic root replacement: results from a prospective randomized trial.

BACKGROUND AND AIM OF THE STUDY: The full homograft root replacement has been regarded as the 'gold standard' for aortic valve replacement (AVR). Xenograft full root AVR may offer similar theoretical advantages, but no prospective randomized trials to compare the two valve substitutes have been reported to date. METHODS: A total of 147 patients (mean age 66.2 years; range: 40-82 years) was randomized to undergo either Medtronic Freestyle (group F; n = 80) or homograft (group H; n = 67) root AVR. Coronary artery bypass grafting was associated with root AVR in 55 patients (37.4%). Follow up included routine clinical and echocardiographic assessments. RESULTS: Overall, there were seven early deaths (4.8%). The early mortality rate for isolated root AVR was 2.1% in group F (1/47) and 2.2% in group H (1/45) (p = NS). There were four late deaths in group F, and two in group H. Actuarial survival was 83+/-5% and 84+/-4% (p = NS) at five years, in groups F and H, respectively. No patient required reoperation on the aortic valve. Overall, there were eight thromboembolic events and six anticoagulant-related bleeding events; these were equally divided between the two groups. After a median follow up of 45 months, most patients in both groups were in NYHA class I, and the mean trans-aortic gradient was 6+/-1 mmHg in group F and 5+/-2 mmHg in group H (p = NS). Mild aortic regurgitation was recorded in 1/26 patients (4%) of group F, and in 1/16 (6%) of group H. CONCLUSION: The Medtronic Freestyle porcine xenograft appears to be a good alternative to homografts for full aortic root replacement, at least in the mid term.