Contemporary Ross procedure outcomes: medium- to long-term results in 214 patients.

OBJECTIVE: Our goal was to present 2 decades of our experience with the Ross procedure and its sequential modifications, adopted since 2010, to improve the reoperation rate. METHODS: We performed a single-centre, retrospective review of database information and medical notes about the implantation technique: the freestanding root. We compared era 1 (1997-2009) and era 2 (2010-2019). RESULTS: Between 1997 and 2019, a total of 214 Ross procedures were performed (71% men, median age 24 years) [interquartile range (IQR) 15-38]. Of these, 87% had various forms of congenital-dysplastic aortic valves. The median cross-clamping and bypass times were 173 (IQR 148-202) and 202 (IQR 182-244) min. The median postoperative stay was 6 days (2-77). Thirty-day mortality was 0.5%. The median follow-up time was 8.2 years (IQR 3.9-13.2). Survival at 10 and 20 years was 97% and 95%; freedom from greater than moderate aortic regurgitation or aortic valve intervention was 91% and 80%; and 93% of the patients were in New York Heart Association functional class I. Twenty (21%) patients operated on during era 1 and 6 (9%) during era 2 underwent autograft reoperations. The median follow-up time was 14.3 (IQR 11.5-17.4) and 4.8 (IQR 2.5-7) years. Freedom from autograft reoperation was 87% and 69% at 10 and 20 years, with no significant difference between eras. Freedom from homograft reoperation was 96% and 76% at 10 and 20 years. The presence of aortic regurgitation, infective endocarditis and era 1 were predictors of autograft reoperation. Male gender and era 1 were predictors of neoaortic root dilatation. CONCLUSIONS: The contemporary modified Ross procedure continues to deliver excellent results and should remain part of the strategy to treat children and young adults requiring aortic valve replacement.

Reoperative coronary bypass surgery using normothermic cardiopulmonary bypass: comparison with first-time procedures.

Redo coronary artery bypass grafting (CABG) is characterized by increased patient risk compared with first-time CABG. The reason for higher risk is not completely understood but it is logically related to inadequate myocardial preservation evidenced by the higher incidence of postoperative low-output syndrome. We compared normothermic cardiopulmonary bypass with cold blood maintenance cardioplegia in both first-time and redo CABGs to determine whether this single approach is appropriate for both instances. Five hundred seventeen consecutive CABG patients were retrospectively reviewed. Four hundred fifty-four first-time CABG procedures were compared with 44 redo procedures. All aspects of the operation were identical including myocardial preservation. Retrospective univariant analysis of both groups followed. Three clinical features distinguished first-time versus redo CABG. These were previous percutaneous transluminal coronary angioplasty (first-time 19% vs redo 71%; P < 0.001), preoperative intra-aortic balloon pump (first-time 38% vs redo 71%; P < 0.001), and Parsonnet risk score (first-time 11.7+/-8.2 vs redo 19.2+/-8.8; P < 0.001). Operative mortality for redo CABG was higher than in first-time procedures (3.4% vs 6.4%; P = not significant), although small sample size limited statistical significance. The length of stay was statistically longer in redo patients (8.7+/-10.8 vs 6.0+/-5.1 days; P < 0.01) and is related to a higher Parsonnet score, increased postoperative pneumonia, and failed percutaneous transluminal coronary angioplasty before redo CABG. We conclude that redo CABG is a different operation from first-time procedures and requires enhanced myocardial preservation. Normothermic cardiopulmonary bypass with cold blood maintenance cardioplegia does not appear to achieve this goal.

Simplified Parsonnet risk scale identifies limits to early patient discharge.

BACKGROUND: Fast-track recovery after coronary artery bypass surgery has influenced patient care positively. Predicting patients who fall off track and require prolonged (> or =7 days) hospitalization remains uncertain. The Parsonnet risk assessment score is effective in predicting length of stay, but is limited by inaccurate subdivision of risk categories. We simplified the Parsonnet risk scale to better identify patients eligible for fast-track recovery. METHOD: The cases of 604 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) were reviewed retrospectively. A rapid recovery protocol emphasizing reduced CPB time, preoperative intra-aortic balloon pump (IABP) criteria, and atrial fibrillation prophylaxis was applied to all patients. The five original divisions of the Parsonnet risk scale were reduced to three risk categories: Low (0-10; Group A), Intermediate (11-20; Group B), High (> 20; Group C). Comparisons of progressive risk categories were analyzed to identify predictive factors associated with fast-track outcomes. RESULTS: The thirty-day operative mortality for the entire group was 3.6%. Three clinical features were identified that distinguished risk progression-female gender, reoperative CABG, and increased age. Additionally, the presence of diabetes (p < 0.05), congestive heart failure (p < 0.01), and peripheral vascular disease (p < 0.001) distinguished Groups A and B, while acute myocardial infarction (p < 0.05) influenced outcomes in Group C. Group A (48%) mean risk score 5.9+/-3.2 was compared to Group B (34%) 14.8+/-2.6, which was further compared to Group C (18%) 26.4+/-2.8. The mean length of stay for Group A (5.3+/-4.1 days) was notably less than Group B (6.1+/-4.7 days; p < 0.05); however, both groups responded favorably to fast-track techniques. Group C did not respond comparably (9.2+/-9.2 vs 6.1+/-4.7 days; p < 0.001) and experienced prolonged recovery. The simplified Parsonnet risk scale did not identify differences in operative mortality and revealed only pneumonia (p < 0.05) and atrial fibrillation (p < 0.01) to be greater in Group C. As risk increased, significantly less revascularization was performed (Group A 3.6+/-1.2 grafts/patient vs Group B 3.3+/-1.2 [p < 0.01]; Group B 3.3+/-1.2 vs Group C 2.5+/-1.0 [p < 0.001]). CONCLUSION: A simplified Parsonnet risk scale (three categories) is an effective tool in identifying factors limiting fast-track recovery. Low- and intermediate-risk patients represent the majority (82%) and respond well to fast-track methods. High-risk patients (18%) are limited by a greater percentage of female patients, reoperative CABG, and the very elderly, resulting in fast-track failure. Strategies to improve recovery in high-risk patients may include evolving off-pump techniques.

Initial experience with beating heart surgery: comparison with fast-track methods.

Cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) may increase postoperative complications in high-risk patients. The goal of this study is to retrospectively review a series of consecutive patients undergoing conventional CABG using a fast-track recovery method and to compare this series with the initial series of patients undergoing beating heart surgery using either the single-vessel minimally invasive approach or the off-pump multivessel bypass technique with a median sternotomy. One hundred fifty-eight consecutive patients underwent CABG. One hundred four patients underwent conventional CABG using CPB with a short-pump fast-track recovery method (Group A). Twenty-nine patients underwent a single-vessel bypass via a left anterior thoracotomy off pump [Group B, minimally invasive direct coronary artery bypass (MIDCAB)]. Twenty-five patients underwent multivessel CABG with a median sternotomy off pump (Group C). Short-pump fast-track (Group A) patients exhibited minimal complications and expedient recovery and received extensive revascularization. Off-pump multivessel patients (Group C) received fewer bypass grafts, had more preoperative comorbidity, and recovered as quickly as lower-risk fast-track short-pump patients (Group A). Single-vessel off-pump patients (Group B, MIDCAB) were younger elective patients and demonstrated no recovery advantage. The overall mortality was 1.8 per cent. The conversion rates from beating heart surgery to CPB for groups B and C were 10.3 and 16 per cent, respectively. The postoperative hospital length of stay for groups A, B, and C were 4.8+/-2.4, 3.9+/-1.8, and 5.2+/-2.3 days, respectively. Eliminating CPB is not as important as reducing exposure for minimizing operative risk. Beating heart surgery is an adjunct to conventional CABG with CPB. The off-pump multivessel bypass technique is best suited for high-risk patients requiring three grafts or fewer, whereas MIDCAB is best suited for single-vessel bypass that cannot be managed using interventional percutaneous techniques; however, the recovery advantage with MIDCAB is not apparent. Patients requiring more than three bypass grafts should undergo conventional CABG with CPB.