Trans-catheter aortic valve replacement program in a community hospital - Comparison with US national data.

Symptomatic aortic stenosis remains a surgical disease, with aortic valve replacement resulting in symptom reduction and improvement in survival. For patients who are deemed a higher surgical risk, Transcatheter aortic-valve replacement (TAVR) is a viable, less invasive and increasingly common alternative. The study compares early outcomes in patients treated within one year of the commencement of TAVR program in a community hospital against outcomes of TAVR patients from nationwide reported data (Society of Thoracic Surgeons/ American College of Cardiology TVT registry). Preoperative characteristics and standardized procedural outcomes of all patients who underwent TAVR in Cape Cod Hospital between June 2015 and May 2016 (n = 62, CCH group) were compared using standardized data format to those of TAVR patients operated during the same time period in other centers within the United States participating in the STS/ACC TVT Registry (n = 24,497, USA group). Most preoperative patient characteristics were similar between groups. However, CCH patients were older (age≥80 years: 77.4% versus 64.3%, p = 0.032) and more likely to be non-elective cases (37.1% versus 9.7%, p<0.001). All 62 TAVR procedures in CCH were performed in the catheterization laboratory unlike most (89.7%) of the procedures in the USA group that were performed in hybrid rooms. A larger proportion of patients in the USA registry underwent TAVR under general anesthesia (78.2% vs.37.1%, P<0.001). Early aortic valve re- intervention rate was 0/62 (0%) in the CCH group VS. 74/ 24,497 (0.3%) in the USA group. In hospital mortality, which was defined as death of any cause during thirty days from date of operation, (CCH: 0% vs. USA: 2.5%, p = 0.410) and occurrence of early adverse events (including postoperative para-valvular leaks, conduction defects requiring pacemakers, neurologic and renal complications) were similar in the two groups. The study concludes that with specific team training and co-ordination, and with active support of experienced personnel, high risk patients with severe aortic valve stenosis can be managed safely with a TAVR procedure in a community hospital.

Automated fastener (Core-Knot) versus manually tied knots in patients undergoing aortic valve replacement: Impact on cross-clamp time and short-term echocardiographic results.

The Core-Knot device is an automatic fastener used mainly in minimally invasive heart valve surgery procedures, to facilitate knot tying. The purpose of this report is to compare ischemic time and outcomes of surgical aortic valve replacements (SAVRs) utilizing the Core-Knot device compared with manually tied knots.Between January, 2014 and December, 2016, 119 patients underwent SAVR in Cape Cod Hospital. We compared patient's characteristics, cross-clamp time, and outcomes of 75 patients who underwent SAVR using Core-Knot to those of 44 operated using manually tied knots.Patient characteristics were similar between groups. Patients in the Core-Knot group had higher preoperative aortic valve area and higher ejection fraction. The use of Core-Knot was associated with reduced aortic cross-clamp time (median 70 vs 84 minutes; P < .001). Patients undergoing SAVR using Core-Knot were less likely to have postoperative aortic regurgitation (P < .001). Early mortality, and also the rates of early adverse events (including all cardiac, neurologic, and renal complications), and the immediate postprocedure echo findings were similar in the 2 groups. In multivariate analysis, the use of Core-Knot was associated with reduced postoperative mean gradient across the aortic valve and reduced occurrence of postoperative aortic regurgitation. Older age and larger valve size were other predictors of reduced postoperative mean gradients.The use of an automatic fastener (Core-Knot) in surgical aortic valve replacement cases reduce aortic cross-clamp time and help eliminate postoperative paravalvular aortic regurgitation.

Coronary Endarterectomy or Patch Angioplasty for Diffuse Left Anterior Descending Artery Disease.

BACKGROUND: Coronary endarterectomy and patch angioplasty for the left anterior descending (LAD) artery have been shown to be effective adjunct techniques to surgical revascularization for severe coronary lesions. The objective of this study is to review the short- and long-term results of these two methods in our institution. METHODS: We retrospectively reviewed 166 consecutive patients who underwent internal thoracic artery grafting to the LAD, with either adjunct endarterectomy (95 patients) or patch angioplasty (71 patients) between 2002 and 2014. We compared the early and late outcomes between groups. RESULTS: The endarterectomy patients were older than the patch angioplasty patients (71 vs. 67 years, p = 0.007) and had lower rates of recent myocardial infarction (25% vs. 45%, respectively, p = 0.008). Median pulmonary bypass times and aortic cross clamp times were significantly longer in the endarterectomy group compared with the patch angioplasty group by 47 minutes (p < 0.001) and 42 minutes (p < 0.001), respectively. Median follow-up time was 6.9 years. No significant differences in operative mortality, perioperative myocardial infarction, and long-term survival were found. Freedom from percutaneous coronary intervention at 1 and 5 years was significantly higher in the endarterectomy group compared with the patch angioplasty group (p = 0.002). CONCLUSIONS: Endarterectomy and patch angioplasty are comparable methods to reach complete revascularization for highly selected patients with diffuse atherosclerotic disease in the LAD. Compared with patch angioplasty, complete extraction of the atherosclerotic plaque with an endarterectomy leads to similar short-term outcomes and long-term survival while significantly reducing the need for further interventions in the future.

Survey of the clinical assessment and utility of near-infrared cerebral oximetry in cardiac surgery.

OBJECTIVES: Near-infrared cerebral oximetry increasingly is used for monitoring during cardiac surgery. Nonetheless, the scientific basis for incorporating this technology into clinical practice, the indications for when to do so, and standard diagnostic and treatment algorithms for defining abnormal values are yet to be rigorously defined. The authors hypothesized that there would be (1) variation in clinical use and practices for near-infrared spectroscopy (NIRS), and (2) variation in management of patients when clinicians are provided with NIRS information. In order to test this hypothesis, they sought to assess the nature and strength of response heterogeneity among anesthesiologists and cardiac perfusionists when provided with cardiac surgery patient scenarios and cerebral oximetry data. DESIGN: A prospectively collected survey. SETTING: A hospital-based, multi-institutional, multinational study. PARTICIPANTS: By e-mail, the authors surveyed the membership of the Society of Cardiovascular Anesthesiologists and the online Cardiovascular Perfusion Forum. INTERVENTIONS: This survey was focused on ascertaining what actions clinicians would take in each scenario, given case information and cerebral oximetry tracings. Questions were based on 11 patient scenarios selected to represent small, large, symmetric, or asymmetric decreases in measured regional cerebral oxygen saturation (rScO2) encountered during cardiac surgery. Information on the respondents' (n = 796; 73% anesthesiologists) clinical practice, demography, and cerebral oximetry utilization was collected. An index of dispersion was used to assess response heterogeneity overall and within demographic subgroups. MEASUREMENTS AND MAIN RESULTS: The majority of respondents indicated that cerebral oximetry monitoring was either useful or an essential monitor, especially perfusionists and clinicians who used cerebral oximetry most frequently. There were marked differences in responses between perfusionists and anesthesiologists for 4 of the 6 scenarios (p<0.005 for each of these 4 scenarios) occurring during cardiopulmonary bypass. Scenarios having greatest rScO2 reduction or asymmetry in rScO2 were associated with the highest dispersion, indicating least agreement in management. Scenarios with mild or moderate rScO2 reduction were associated with the lowest dispersion, indicating greater agreement in management. CONCLUSIONS: Although experimental data gradually are accumulating to support the role for cerebral oximetry monitoring during cardiac surgery, the results of the present survey support the view that its role remains poorly defined, and consensus for its appropriate use is lacking. Importantly, the authors observed marked variation in the use, perceived utility, and management of patients for 4 of the 6 CPB scenarios between perfusionists and anesthesiologists who share the management of CPB. These findings support the need for well-designed, adequately-powered clinical trials examining the value of this technology.

Renoprotective effect of preoperative statins in coronary artery bypass grafting.

The renoprotective effect of preoperative statin use in coronary artery bypass grafting remains poorly defined. A retrospective review of 1,802 consecutive patients who underwent isolated coronary artery bypass grafting from January 2002 to October 2005 was performed. Of those, 1,039 patients were receiving statins preoperatively, and 763 patients were not. Two propensity score-matched cohorts each of 641 patients (statin and nonstatin groups) were constructed. Multivariate logistic regression analyses for matched patients and all patients were performed to investigate whether preoperative statin use was associated with the incidence of new renal insufficiency. In a matched analysis, the statin group had a lower incidence of new renal insufficiency than the nonstatin group (1.6% vs 3.9%, odds ratio 0.39, 95% confidential interval 0.18 to 0.82, p = 0.01). Multivariate logistic regression analysis including all patients also showed that preoperative statin use (odds ratio 0.54, 95% confidence interval 0.30 to 0.99, p = 0.047) was significantly associated with low incidence of new postoperative renal insufficiency. In conclusion, preoperative statin use may be renoprotective after coronary artery bypass grafting.

Replacement of the quadricuspid aortic valve: strategy to avoid complete heart block.

Quadricuspid aortic valves are rarely encountered by the cardiac surgeon during aortic valve replacement. The most common location for the supranumerary cusp is between the noncoronary and the right coronary cusp, located over the membranous septum, which can potentially increase the risk of complete heart block after valve replacement. We present three quadricuspid aortic valve replacements, one of which was complicated by complete heart block postoperatively. We suggest a strategy to possibly avoid this complication.

Early results of a comprehensive operative and perfusion strategy to attenuate the incidence of adverse neurological outcomes in on-pump coronary artery bypass grafting (CABG) patients.

Adverse neurological events, both focal (Type I) and non-focal (Type II), have been appreciated in postoperative on-pump coronary artery bypass grafting (CABG) patients for many years. Advanced age is a significant risk factor for adverse neurological events following CABG surgery. With full knowledge that our elderly population of patients was at high risk for these untoward neurological events, we adopted a comprehensive operative and perfusion strategy in an attempt to attenuate the incidence of these complications. Our strategy included efforts to minimise the number of emboli generated during the operation, avoid cerebral hypoperfusion, and attenuate the systemic inflammatory response. From 15 August 2002 to 31 December 2005, we performed 355 on-pump CABG operations. The incidence of Type I focal injury was 0/355 (0%), the incidence of Type II non-focal injury was 9/355 (2.5%), and postoperative mortality was 2/355 (0.6%). These results compared favorably to the results predicted by the Society of Thoracic Surgeons' (STS) model, and may suggest efficacy.