Faculty Bibliography

BACKGROUND: There are limited data in the literature concerning the effect of a blood conservation strategy (BCS) on aortic valve replacement (AVR) patients. METHODS: From 2007 to 2011, 778 patients underwent AVR at a single institution. During this period, a multidisciplinary BCS was initiated with emphasis on limiting intraoperative hemodilution, tolerance of perioperative anemia, and blood management education for the cardiac surgery care providers. RESULTS: Mortality was 3.0% (23 of 778) overall and 1.7% (9 of 522) for isolated first-time AVR. There was no difference in rates of mortality (p = 0.5) or major complications (p = 0.4) between the pre-BCS and post-BCS groups; however, the BCS was associated with a lower risk of major complications (odds ratio, 1.7; p = 0.046) by multivariable analysis. The incidence of red blood cell (RBC) transfusion decreased from 82.9% (324 of 391) to 68.0% (263 of 387; p < 0.01). Of those patients who did not receive any day-of-operation RBC transfusions, 64.5% (191 of 296) did not receive any postoperative RBC transfusions. Lower risk of RBC transfusion was associated with isolated AVR (p < 0.01), a minimally invasive approach (p < 0.01), and BCS (p < 0.01), whereas a greater risk of RBC transfusion was associated with older age (p < 0.01), prior cardiac operation (p = 0.01), female sex (p < 0.01), and smaller body surface area (p < 0.01). Day-of-operation RBC transfusion of 2 units or more was associated with increased deaths (p = 0.01), prolonged intubation (p < 0.01), postoperative renal failure (p = 0.01), and increased incidence of any complication (p < 0.01). CONCLUSIONS: Perioperative BCS reduced RBC transfusion in AVR patients without an increase in mortality or morbidity. Guidelines for BCS in routine cardiac operations should be extended to AVR patients.

OBJECTIVE: Recent Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists (STS/SCA) guidelines highlight the safety of blood conservation strategies in routine cardiac surgery. We evaluated the feasibility and impact of such a program in complex aortic surgery. METHODS: Between March 2010 and October 2011, 63 consecutive aortic replacement procedures were performed: aortic root (n = 17; 27%), ascending aorta (n = 15; 23.8%), aortic arch (n = 19; 30.2%), descending aorta (n = 8; 12.7%), and thoracoabdominal aorta (n = 4; 6.3%). Aortic dissections were present in 32 patients. A multidisciplinary approach to blood conservation included minimal perioperative crystalloid, small priming circuits, hemoconcentration, meticulous hemostasis, and tolerance of postoperative anemia (hemoglobin of >/= 7mg/dL). RESULTS: Operative mortality was 11.1%. Multivariate predictors of mortality were low preoperative hematocrit (HCT, P = 0.05) and endocarditis (P = 0.021). Seventy-four percent of patients required no intraoperative packed red blood cell (pRBC) transfusion. For nondissection patients, 80.6% required /= 2 U (P = 0.001). CONCLUSIONS: These findings demonstrate that a perioperative blood conservation management strategy can be extended to complex aortic surgery and is associated with better clinical outcomes.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly present in approximately one in 300,000 live births. Here, we present a unique ALCAPA variant identified in a neonate. The left anterior descending artery originated posterolaterally on the main pulmonary artery, and the circumflex originated separately from the distal right pulmonary artery. doi: 10.1111/jocs.12079 (J Card Surg 2013;28:306-308).

Infectious complications related to retained temporary epicardial pacing wires are rare. We report a case of a focal retroaortic abscess in association with retained pacing wires that became manifest 3 years after surgery for tricuspid valve endocarditis.

Obesity and rapid weight loss after bariatric surgery is associated with, the development of cholelithiasis and related complications. Several algorithms have been suggested in the management of the asymptomatic gallstones in patients presenting for weight loss surgery (WLS). Charts of patients presenting for laparoscopic Roux-en-Y (LRYGB) were retrospectively reviewed. Concomitant or delayed cholecystectomies were performed for symptomatic disease at the time of or after LRYGB, respectively. A total of 1376 patients underwent LRYGB and 21.0 per cent had a history of a cholecystectomy. An additional 2.7 per cent underwent cholecystectomy. The remaining 1050 "at-risk" patients were followed for a mean of 32.3 months and 4.9 per cent underwent delayed cholecystectomy for symptomatic disease. Of these patients, 88.5 per cent presented within 2 years of LRYGB. No significant morbidities were experienced by the "at-risk" cohort. Currently, there is no consensus in the treatment of asymptomatic cholelithiasis in patients presenting for WLS. A conservative regimen of reserving cholecystectomy for symptomatic disease is safe in patients undergoing LRYGB. Subsequent cholecystectomy was required in 4.9% with the majority of these patients presenting within 2 years of LRYGB. Further investigations in the form of randomized, prospective studies are necessary to clearly define the indications for cholecystectomy at the time of WLS.