Faculty Bibliography

The physiologic impact of pulsatile flow (PF) on end-organ perfusion during cardiopulmonary bypass (CPB) is controversial. Using an intra-aortic balloon pump (IABP) to maintain PF during CPB for patients undergoing heart transplantation (HT) may impact end-organ perfusion, with implications for postoperative outcomes. A single-center retrospective study of 76 patients bridged to HT with IABP was conducted between January 2018 and December 2022. Beginning in May 2022, patients received IABP-generated PF during CPB at an internal rate of 80 beats/minute. Fifty-eight patients underwent HT with the IABP turned off (IABP-Off), whereas 18 patients underwent HT with IABP-generated PF (IABP-On). The unmatched IABP-On group experienced shorter organ ischemia times (180 vs. 203 minutes, p = 0.015) and CPB times (104 vs. 116 minutes, p = 0.022). The cohort was propensity matched according to age, organ ischemia time, and CPB time. Elevations in postoperative lactates in the immediate (2.8 vs. 1.5, p = 0.062) and 24 hour (4.7 vs. 2.4, p = 0.084) postoperative periods trended toward significance in the matched IABP-Off group. There was no difference in postoperative vasoactive inotropic score (VIS), postoperative creatinine, or length of stay. This limited preliminary data suggest that maintaining counterpulsation to generate PF during CPB may improve end-organ perfusion in this patient population as suggested by lower postoperative lactate levels.

BACKGROUND:Drug overdose (DO) deaths rose to unprecedented levels during the coronavirus disease 2019 (COVID-19) pandemic. This study examines the impact of COVID-19 on the availability of cardiac allografts from DO donors and the implications of DO donor use on recipient survival. METHODS:Heart transplants reported to the United Network for Organ Sharing from January 2017 to November 2019 ("pre-COVID") and from March 2020 to June 2021 ("COVID pandemic") were analyzed with respect to DO donor status. Outcomes were analyzed using Kaplan-Meier survival and Cox regression to identify predictors of survival. Characteristics of discarded cardiac allografts were also compared by DO donor status. RESULTS:During the COVID-19 pandemic, 27.2% of cardiac allografts were from DO donors vs 20.5% pre-COVID, a 32.7% increase (p < 0.001). During the pandemic, DO donors were younger (84.7% vs 76.3% <40 years, p < 0.001), had higher cigarette use (16.1% vs 10.8%, p < 0.001), higher cocaine use (47.4% vs 19.7%, p < 0.001), and higher incidence of hepatitis C antibodies (26.8% vs 6.1%, p < 0.001) and RNA positivity (16.2% vs 4.2%, p < 0.001). While DO donors were less likely to require inotropic support (30.8% vs 35.4%, p = 0.008), they were more likely to have received cardiopulmonary resuscitation (95.3% vs 43.2%, p < 0.001). Recipient survival was equivalent using Kaplan-Meier analysis (log-rank, p = 0.33) and survival probability at 36 months was 85.6% (n at risk = 398) for DO donors vs 83.5% (n at risk = 1,633) for all other donors. Cox regression demonstrated that DO donor status did not predict mortality (hazard ratio 1.05; 95% confidence interval 0.90-1.23, p = 0.53). CONCLUSIONS:During the COVID-19 pandemic, there was a 32.7% increase in heart transplants utilizing DO donor hearts, and DO became the most common mechanism of death for donors. The use of DO donor hearts did not have an impact on short-term recipient survival.

BACKGROUND:The benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG). METHODS:The Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation were compared. RESULTS:Between January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG; 891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter postoperative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home (97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P = .04). CONCLUSIONS:Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for nonemergency CABG is indicated.

OBJECTIVE/UNASSIGNED:Totally endoscopic intracardiac robotic surgery is generally limited to uncomplicated mitral valve surgery. With experience, our team has developed a more aggressive approach to robotic cardiac surgery that allows for repair of a broad spectrum of mitral valve pathologies. We report complex subvalvular procedural advancements associated with this approach secondary to enhanced team experience and capabilities. METHODS/UNASSIGNED:All robotic mitral procedures performed by a 2-surgeon team in a quaternary care medical center from July 2011 to May 2022 were reviewed. Natural language-processing techniques were used to analyze operative reports for subvalvular repair techniques. Complex subvalvular techniques included papillary muscle repositioning, division of secondary anterior leaflet chordae, septal myomectomy, division of aberrant left ventricular muscle band attachments, and left ventricular patch reconstruction. The surgical experience was divided into 2 periods: early robotic experience (pre-2018) versus late (2018 onwards). Baseline demographics, outcomes, and subvalvular techniques were analyzed and compared. RESULTS/UNASSIGNED: < .001)). CONCLUSIONS/UNASSIGNED:An experienced 2-surgeon team can perform progressively more complex robotic subvalvular repair techniques. These subvalvular techniques are a surrogate for team proficiency and capabilities.

OBJECTIVE/UNASSIGNED:Endoaortic balloon occlusion facilitates cardioplegic arrest during minimally invasive surgery (MIS). Studies have shown endoclamping to be as safe as traditional aortic clamping. We compared outcomes and hospital costs of endoclamping versus external aortic occlusion in a large administrative database. METHODS/UNASSIGNED:= 1,244). Generalized linear modeling measured differences in in-hospital complications (major adverse renal and cardiac events, including mortality, new-onset atrial fibrillation, acute kidney injury [AKI], myocardial infarction [MI], postcardiotomy syndrome, stroke/transient ischemic attack [TIA], and aortic dissection) and length of stay (LOS). RESULTS/UNASSIGNED:= 0.005). There were no aortic dissections in the endoclamp group. CONCLUSIONS/UNASSIGNED:Aortic endoclamping in MIS was associated with similar costs, shorter LOS, no dissections, and comparably low mortality and stroke rates when compared with external clamping in this hospital billing dataset. These results demonstrate the clinical safety and efficacy of endoaortic balloon clamping in a real-world setting. Further studies are warranted.

BACKGROUND/UNASSIGNED:Evidence suggests that patients critically ill with COVID-19 have a dysregulated host immune response that contributes to end-organ damage. Extracorporeal membrane oxygenation (ECMO) has been used in this population with varying degrees of success. This study was performed to evaluate the impact of ECMO on the host immunotranscriptomic response in these patients. METHODS/UNASSIGNED:Eleven patients critically ill with COVID-19 requiring ECMO underwent an analysis of cytokines and immunotranscriptomic pathways before ECMO (T1), after ECMO for 24 hours (T2), and 2 hours after ECMO decannulation (T3). A Multiplex Human Cytokine panel was used to identify cytokine changes, and immunotranscriptomic changes in peripheral leukocytes were evaluated by PAXgene and NanoString nCounter. RESULTS/UNASSIGNED:, which code for binding ligands for the activation of toll-like receptors 2 and 4. Reactome analyses of differential gene expression demonstrated an impact on many of the body's most important immune inflammatory pathways. CONCLUSIONS/UNASSIGNED:These findings suggest a temporal impact of ECMO on the host immunotranscriptomic response in patients critically ill with COVID-19.

Objective: Endoaortic balloon occlusion, or endoclamping, facilitates cardioplegic arrest during minimally invasive surgery (MIS). Limited research has shown endoclamping to be as safe as traditional aortic clamping. This study compares outcomes after cardiac surgery utilizing endoclamping as compared with traditional methods of aortic occlusion in a broader, real-world setting.
Method(s): 52,882 adults undergoing eligible cardiac surgery (10/2015-3/2020) were identified by administrative data from the Premier Hospital Dataset. Endoclamp MIS procedures (n=419) were 1:3 propensity score matched to similar procedures performed using traditional aortic occlusion methods (primarily external clamping, n=1244). Comparison procedures were selected by procedure type, and absence of: known sternotomy (a proxy for MIS), CABG, or concomitant aortic surgery. Generalized linear modeling measured differences in in-hospital complications [major adverse renal and cardiac events (MARCE, including mortality, new onset atrial fibrillation, acute kidney injury, myocardial infarction, postcardiotomy syndrome, stroke/TIA) and aortic dissection], and length of stay.
Result(s): Mean age was 63 years, and 53% were male (n=882). The majority (93%, n=1543) were mitral valve procedures and the remainder were atrial septal defect, left atrial appendage occlusion and/or tricuspid valve procedures. 1 in 6 (17%, n=285) procedures were robotic-assisted and 1% (n=20) were re-operations at the same index hospital. The endoclamp group exhibited lower MARCE rates as compared to the comparison external clamping group, with borderline difference at P<0.10: 22% vs. 26% (odds ratio (OR)=0.78, P=0.0611). Lower MARCE rates appeared to be driven largely by myocardial infarction (OR=0.14, P=0.0061) and postcardiotomy syndrome (OR=0.27, P=0.0051). No endoclamp patients experienced aortic dissection. Rates of mortality, atrial fibrillation, acute kidney injury and stroke/TIA were not significantly different between the 2 groups. Median length of stay was significantly shorter with endoclamping vs. external clamping methods (incident rate ratio=0.87, P=<0.0001).
Conclusion(s): Endoclamping was associated with shorter hospital stays, no dissections and comparable low mortality and stroke rates when compared to traditional external clamping techniques in this hospital billing dataset. These results demonstrate the clinical safety and efficacy of endoclamping in a real-world setting. Further studies are warranted. (Table Presented)

We compare outcomes of endo-aortic balloon occlusion (EABO) vs external aortic clamping (EAC) in patients undergoing minimally invasive mitral valve surgery (MIMVS) in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Adults undergoing mitral valve surgery (July 2017-December 2018) were identified within the STS database (N = 60,607). Total 7,978 patients underwent a minimally invasive approach (including robotically assisted). About 1,163 EABO patients were 1:1 propensity-matched to EAC patients using exact matching on age, sex, and type of mitral procedure, and propensity score average matching for 16 other risk indicators. Early outcomes were compared. Categorical variables were compared using logistic regression; hospital and intensive care unit length of stay were compared using negative binomial regression. In the matched cohort, mean age was 62 years; 35.9% were female, and 86% underwent mitral valve repair. Cardiopulmonary bypass time was shorter for EABO vs EAC group (125.0 ± 53.0 vs 134.0 ± 67.0 minutes, P = 0.0009). There was one aortic dissection in the EAC group and none in the EABO group (P value > 0.31), and no statistically significant differences in cross-clamp time, major intraoperative bleeding, perioperative mortality, stroke, new onset of atrial fibrillation, postoperative acute kidney injury, success of repair. Median hospital LOS was shorter for EABO vs EAC procedures (4 vs 5 days, P < 0.0001). In this large, retrospective, STS database propensity-matched analysis ofpatients undergoing MIMVS, we observed similar safety outcomes for EABO and EAC, including no aortic dissections in the EABO group. The EABO group showed slightly shorter CPB times and hospital LOS.

Background: The use of rapid-deployment valves (RDVs) has been shown to reduce the operative time for surgical aortic valve replacement (AVR). Long-term core laboratory"“adjudicated data are scarce, however. Here we report final 7-year data on RDV use. Methods: TRANSFORM was a prospective, nonrandomized, multicenter, single-arm trial implanting a stented bovine pericardial valve with an incorporated balloon-expandable sealing frame. A prior published 1-year analysis included 839 patients from 29 centers. An additional 46 patients were enrolled and implanted, for a total of 885 patients. Annual clinical and core laboratory"“adjudicated echocardiographic outcomes were collected through 8 years. Primary endpoints were structural valve deterioration (SVD), all-cause reintervention, all-cause valve explantation, and all-cause mortality. Secondary endpoints included hemodynamic performance assessed by echocardiography. The mean duration of follow-up was 5.0 ± 2.0 years. Results: The mean patient age was 73.3 ± 8.2 years. Isolated AVR was performed in 62.1% of the patients, and AVR with concomitant procedures was performed in 37.9%. Freedom from all-cause mortality at 7 years was 76.0% for isolated AVR and 68.2% for concomitant AVR. Freedom from SVD, all-cause reintervention, and valve explantation at 7 years was 97.5%, 95.7%, and 97.8%, respectively. The mean gradient and effective orifice area at 7 years were 11.1 ± 5.3 mm Hg and 1.6 ± 0.3 cm², respectively. Paravalvular leak at 7 years was none/trace in 88.6% and mild in 11.4%. In patients undergoing isolated AVR, the cumulative probability of pacemaker implantation was 13.9% at 30 days, 15.5% at 1 year, and 21.8% at 7 years. Conclusions: AVR for aortic stenosis using an RDV is associated with low rates of late adverse events. This surgical pericardial tissue platform provides excellent and stable hemodynamic performance through 7 years.