Faculty Bibliography

Introduction: Cardiogenic shock is associated with high in-hospital mortality rates regardless of etiology. Recently, there has been an increase in utilization of acute mechanical circulatory support (MCS) in patients with cardiogenic shock. Although there is no consensus as to the most appropriate device for any particular patient presentation, acute MCS devices have been widely adopted in institutions that favor an aggressive approach to cardiogenic shock. Establishment of an Adult ECMO Program at our institution has led to experience with additional acute MCS devices. The complexity of these clinical situations led to the creation of a multidisciplinary team, including a combination of cardiologists, surgeons, interventionalists, and intensivists, committed to treating these patients. As an early ECMO Program and Cardiogenic Shock Team, we sought to review our early experience with acute MCS for cardiogenic shock to define our baseline strategies and outcomes in this patient population. Materials and Methods: We completed a retrospective review of cardiogenic shock patients who were treated with acute MCS by Fiscal Year (September 1 to August 31) beginning with Fiscal Year (FY) 2014. We reviewed implant volume by device, including temporary surgical ventricular assist device (VAD), percutaneous and surgical Impella, percutaneous RVADs, and veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO). Data collected included etiology of shock, indication for device implantation, type of support offered, length of support, and outcome of support. For each category of device, we also reviewed our outcomes by mirroring the established ELSO benchmarks of "Survival from ECMO" and "Survival to Discharge." Results: We found a steady increase in the use of acute MCS for treatment of cardiogenic shock from FY 2014 to FY 2018. From FY 2014 to 2015 there was an increase from zero to 18 implants. The following year (FY 2016) revealed a 100% increase, with a total of 36 implants. The volume increased more slowly (16%/year) the following two years (FY 2017, FY 2018) with 43 and 48 implants, respectively. Overall outcome assessment revealed that 68% of patients survived acute MCS and 53% of patients survived to hospital discharge with an increased survival to discharge in the last fiscal year to 62%. Conclusion: Creation of an Adult ECMO Program and a multidisciplinary Cardiogenic Shock Team correlated with an increase in the number of patients supported with acute MCS. As the team gains experience with these patients and the devices available to support them, we expect the outcomes to continue to improve. Patient selection, surgical approaches and techniques, standardizing medical therapy, and managing and reducing complications will give these patients the best opportunity to survive

A 78 year-old man with remote type-A dissection presented with acute-onset dyspnea. Twenty-two years prior, treatment for his aortic disease required replacement of ascending and arch aneurysms with a Dacron graft using graft inclusion technique. He presented currently in cardiogenic shock. Echocardiography demonstrated new severe hypokinesis of all apical segments. Left-heart catheterization revealed a 120mmHg intra-graft gradient. CT arteriography was unrevealing, but intra-aortic ultrasound demonstrated critical intra-graft stenosis. A Palmaz stent was deployed in the stenotic region with gradient resolution. He later underwent aortic root replacement and ascending aneurysm repair (Bio-Bentall technique) and is doing well at 24 months.

PURPOSE OF REVIEW/OBJECTIVE:Many patients suffer from either persistent right ventricular failure (RVF) at the time of left ventricular assist device (LVAD) or have ongoing symptoms consistent with RVF during chronic mechanical circulatory support. The lack of long-term right ventricular assist devices (RVADs) has limited the impact that mechanical circulatory support can provide to patients with biventricular failure. We aim to review the entire spectrum of RVF in patients receiving LVADs and reflect on why this entity remains the Achilles' heel of LVAD therapy. RECENT FINDINGS/RESULTS:In the early postoperative period, LVAD implantation reduces right ventricle (RV) afterload, but RV dysfunction may be exacerbated secondary to increased venous return. With prolonged therapy, the decreased RV afterload leads to improved RV contractile function. Bayesian statistical models outperform previously published preoperative risk scores by considering inter-relationships and conditional probabilities amongst independent variables. Various echocardiographic parameters and the pulmonary artery pulsatility index have shown promise in predicting post-LVAD RVF. Recent publications have delineated the emergence of 'delayed' RVF. Several devices are currently being investigated for use as RVADs. SUMMARY/CONCLUSIONS:Post-LVAD RVF depends on the RV's ability to adapt to acute hemodynamic changes imposed by the LVAD. Management options are limited due to the lack of an easily implantable, chronic-use RVAD.

BACKGROUND:We analyzed the impact and safety of del Nido Cardioplegia (DNC) in patients undergoing minimally invasive aortic valve replacement (MIAVR). METHODS:We analyzed all isolated MIAVR replacements from 5/2013-6/2015 excluding re-operative patients. The approach was a hemi-median sternotomy in all patients. Patients were divided into two cohorts, those who received 4:1 crystalloid:blood DNC solution and those in whom standard 1:4 Buckberg-based cardioplegia (WBC) was used. One-to-one propensity case matching of DNC to WBC was performed based on standard risk factors and differences between groups were analyzed using chi-square and non-parametric methods. RESULTS:MIAVR was performed in 181 patients; DNC was used in 59 and WBC in 122. Case matching resulted in 59 patients per cohort. DNC was associated with reduced re-dosing (5/59 (8.5%) versus 39/59 (61.0%), P < 0.001) and less total cardioplegia volume (1290 ± 347 mL vs 2284 ± 828 mL, P < 0.001). Antegrade cardioplegia alone was used in 89.8% (53/59) of DNC patients versus 33.9% (20/59) of WBC patients (P < 0.001). Median bypass and aortic cross-clamp times were similar. Clinical outcomes were similar with respect to post-operative hematocrit, transfusion requirements, need for inotropic/pressor support, duration of intensive care unit stay, re-intubation, length of stay, new onset atrial fibrillation, and mortality. CONCLUSIONS:Del Nido cardioplegia usage during MIAVR minimized re-dosing and the need for retrograde delivery. Patient safety was not compromised with this technique in this group of low-risk patients undergoing MIAVR.

Objective: The longer dosing interval afforded by Del Nido cardioplegia (DNC) may simplify myocardial protection strategies. We analyzed the impact and safety of DNC in patients undergoing minimally invasive aortic valve replacement. Methods: Institutional use of DNC began in May 2013; we analyzed all isolated minimally invasive aortic valve replacements during this transition (May 2013-June 2015), excluding reoperative sternotomy patients. The approach was hemi-median sternotomy in all patients. Prospectively collected local and Society of Thoracic Surgeons database data were used. Patients were divided into 2 cohorts: those who received 4:1 crystalloid:blood DNC solution and those in whom standard 1:4 Buckberg-based cardioplegia (BC) was used. One-to-one propensity case matching of DNC to Buckberg-based cardioplegia was performed based on standard risk factors, and differences between groups were analyzed using X² and nonparametric methods. Results: Minimally invasive aortic valve replacement was performed in 181 patients; DNC was usedin 59 and Buckberg-based cardioplegia in 122. Case matching resulted in 59 patients per cohort. DNC was associated with reduced re-dosing [5/59 (8.5%) vs. 39/59 (61.0%), P<0.001] and less total cardioplegia volume (1290 ml+/-347 ml vs. 2284 ml+/-828 ml, P<0.001). Antegrade cardioplegia alone was used in 89.8% (53/59) of DNC patients versus 33.9% (20/59) of patients receiving Buckberg-based cardioplegia (P<0.001). Median bypass and aortic cross-clamp times were similar. Clinical outcomes were similar with respect to postoperative hematocrit, transfusion requirements, need for inotropic/pressor support, duration of stay in the intensive care unit, re-intubation, length of hospital stay, new onset atrial fibrillation, and mortality rate. Table SA15-1 contains demographics, cardioplegia delivery methods, and results. Conclusions: DNC usage markedly simplifies cardioplegia strategy for minimally invasive aortic valve replacement. Patient safety was not compromised with this technique. (Table pasented)

Cardiac surgery patients with infected implantable cardioverter defibrillator hardware face high morbidity with both surgical and nonoperative management options. We present a case of infected epicardial patch defibrillator leads in a patient with prohibitively high risk of death with open surgical removal. As a less morbid alternative, an Eloesser flap was used to convert his presenting mediastinal empyema necessitans into a chronic, manageable wound.

OBJECTIVE: Although the benefits of minimally invasive valvular surgery are well established, the applicability of extending these techniques to reoperative aortic valve surgery is unknown. We evaluated our experience with a minimally invasive approach to this patient population. METHODS: From January 2010 to September 2015, 21 patients underwent reoperative isolated aortic valve replacement via a minimally invasive approach by a single surgeon. All patients had preoperative evaluation with computerized tomography and coronary catheterization. Surgical approaches were right anterior thoracotomy (6/21) or upper hemisternotomy (15/21). Central aortic cannulation was preferred with femoral artery cannulation used in four patients (19%). In patients with left internal mammary artery (LIMA) grafts, no attempt to dissect or occlude the graft was made. Cold blood cardioplegia was administered antegrade (12/21) or retrograde (9/21); systemic cooling with a mean low temperature of 27.5 degrees C was employed. RESULTS: Mean age was 75.1 years with a range from 33 to 92 years, and 67% (14/21) were male. All procedures were completed with a minimally invasive approach. Mean +/- SD cross-clamp time was 51.5 +/- 9.2 minutes. Fourteen patients had patent LIMA grafts. No aortic, LIMA, or cardiac injuries occurred. There were no hospital deaths nor occurrences of perioperative myocardial infarction, stroke, wound infection, renal failure, or endocarditis/sepsis. One patient required a reoperation for bleeding. Sixty-two percent of patients were discharged to home; mean +/- SD length of stay was 6 +/- 3 days. CONCLUSIONS: With appropriate preoperative evaluation and careful surgical planning, a minimally invasive approach to reoperative aortic valve surgery can be performed in a safe and effective manner.

PURPOSE: Driveline exit site (DLES) management following left ventricular assist device implantation is important for preventing driveline infection (DLI). While chlorhexidine gluconate (CHG) is generally recommended for DLES antisepsis, CHG intolerance can develop, resulting in a need for alternative antiseptics. We reviewed our institutional experience with DLES antisepsis methods in HeartMate II patients, comparing outcomes of patients with and without CHG intolerance. METHODS: Between October 2011 and March 2016, 44 patients underwent primary HeartMate II implantation. CHG was used for DLES antisepsis and povidone-iodine (PVP-I) was used in patients with CHG intolerance. DLI was defined by Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) criteria. RESULTS: Of 44 patients, 37 (84%) received CHG and 7 (16%) received PVP-I antisepsis due to CHG intolerance. Five patients (11.4%) developed a DLI, with an event per patient-year rate of 0.07. Median length of support was 521 days (interquartile range 202-881 days). Characteristics were similar between patients with and without DLI. However, a larger proportion of patients with DLI had CHG intolerance compared to patients without DLI (60.0% vs. 10.3%, p:0.05). Causative organisms were Staphylococcus aureus in CHG-intolerant patients and Stenotrophomonas and Acinetobacter in CHG-tolerant patients. Kaplan-Meier method and log-rank test demonstrated decreased infection-free days in patients using PVP-I rather than CHG (p:0.01). CONCLUSIONS: While the etiology of DLI is multifactorial, CHG intolerance appears to be a risk factor. Our findings highlight the need for larger studies comparing the efficacy of antiseptics for DLES care, particularly for patients with CHG contraindications.

This monograph outlines the rich history of cardiothoracic surgery at New York University (NYU), beginning with its origins at The Bellevue Hospital in the mid-1800's. Numerous early clinical accomplishments were significant, leading up to the arrival of Dr Frank Spencer in 1966. Under Dr Spencer's leadership, the department progressed with development of a culture of innovation, leadership and education that carries through today. The program encompasses three major hospitals and will soon graduate its 50th class of trainees, many of whom have had outstanding careers and a major impact on the field of cardiothoracic surgery. This culture continues under the direction of our current chair, Dr Aubrey Galloway, whose vision has orchestrated and refined a new period of innovation and excellence.