Faculty Bibliography

The shortage of lungs for organ donation is problematic, and meeting the demand by expanding the donor pool in lung transplantation is critical. Donation after cardiac death (DCD) is an under-used approach that could be a valuable source of organs. However, procuring lungs from donors with a previous median sternotomy is technically difficult and is usually avoided. Here, we describe the procurement of lungs from a DCD patient with a previous median sternotomy.

OBJECTIVES:To determine the value of surgery for infective endocarditis (IE) in patients on hemodialysis by comparing the nature and invasiveness of endocarditis in hemodialysis and nonhemodialysis patients and their hospital and long-term outcomes, and identifying risk factors for time-related mortality after surgery. METHODS:From January 1997 to January 2013, 144 patients on chronic hemodialysis and 1233 nonhemodialysis patients underwent valve surgery for IE at our institution. Propensity matching identified 99 well-matched hemodialysis and nonhemodialysis patient pairs for comparison of outcomes. RESULTS:Staphylococcus aureus infection was more common in hemodialysis patients than in nonhemodialysis patients (42% vs 21%; P < .0001), but invasive disease was similar in the 2 groups (47%; P = .3). Hospital mortality was 13% and 5-year survival was 20% for hemodialysis patients, 20% below that expected in a general hemodialysis population but 15% above that of hemodialysis patients treated nonsurgically for IE. For matched patients, hospital mortality was 13% for hemodialysis patients versus 5.1% for nonhemodialysis patients (P = .05), and survival at 1 and 5 years was 56% versus 83% and 24% versus 59%, respectively (P < .004). Use of an arteriovenous graft for dialysis access (P = .01) and preoperative placement of a pacemaker (P < .0001) were risk factors for late mortality in hemodialysis patients. For matched patients, freedom from reoperation was similar in the hemodialysis and nonhemodialysis groups (P > .9). CONCLUSIONS:Intermediate-term survival after surgery for IE in hemodialysis patients is substantially worse than that in nonhemodialysis patients, but only slightly worse than that in the general hemodialysis population and substantially better than that in hemodialysis patients with IE treated nonsurgically, supporting continued surgical intervention for IE.

Right-sided infective endocarditis (RSIE) is less common than left-sided infective endocarditis (IE), encompassing only 5-10% of cases of IE. Ninety percent of RSIE involves the tricuspid valve (TV). Given the relatively small numbers of TVIE cases operated on at most institutions, the purpose of this review is to highlight and discuss the current understanding of IE involving the TV. RSIE and TVIE are strongly associated with intravenous drug use (IVDU), although pacemaker leads, defibrillator leads and vascular access for dialysis are also major risk factors. Staphylococcus aureus is the predominant causative organism in TVIE. Most patients with TVIE are successfully treated with antibiotics, however, 5-16% of RSIE cases eventually require surgical intervention. Indications and timing for surgery are less clear than for left-sided IE; surgery is primarily considered for failed medical therapy, large vegetations and septic pulmonary embolism, and less often for TV regurgitation and heart failure. Most patients with an infected prosthetic TV will require surgery. Concomitant left-sided IE has its own surgical indications. Earlier surgical intervention may potentially prevent further destruction of leaflet tissue and increase the likelihood of TV repair. Fortunately, TV debridement and repair can be accomplished in most cases, even those with extensive valve destruction, using a variety of techniques. Valve repair is advocated over replacement, particularly in IVDUs patients who are young, non-compliant and have a higher risk of recurrent infection and reoperation with valve replacement. Excising the valve without replacing, it is not advocated; it has been reported previously, but these patients are likely to be symptomatic, particularly in cases with septic pulmonary embolism and increased pulmonary vascular resistance. Patients with concomitant left-sided involvement have worse prognosis than those with RSIE alone, due predominantly to greater likelihood of invasion and abscess formation in left-sided IE. Patients with isolated TVIE have an operative mortality between 0-15% and excellent survival.

Surgical embolectomy in acute pulmonary embolism is usually reserved for patients with massive pulmonary embolism presenting with cardiogenic shock, or for whom thrombolysis is absolutely contraindicated or has failed. Incomplete removal of thrombotic material lodged in the distal pulmonary arterial bed is considered an important cause of persistent pulmonary hypertension. Retrograde pulmonary embolectomy is an adjunct to conventional pulmonary embolectomy, resulting in more complete embolectomy, specifically of material lodged in the distal pulmonary arterial bed. We describe our simplified technique of retrograde pulmonary embolectomy as a safe adjunct to conventional pulmonary embolectomy.

Embolism to the central nervous system is a frequent and important complication of infective endocarditis. While early surgery improves outcomes in many groups of patients with infective endocarditis, ischemic stroke secondary to septic embolism carries the risk of hemorrhagic transformation and neurological deterioration with heparinization and cardiopulmonary bypass. We review the literature regarding the surgical management of infective endocarditis in patients with cerebral emboli.

Esophageal reconstruction by a substernal route with a colonic conduit after previous esophagectomy and end-cervical esophagostomy in the presence of a patent left internal thoracic artery graft to the left anterior descending coronary artery is a technically challenging procedure. In this case report, we describe a safe approach to this difficult problem. With proper planning and careful dissection, substernal esophageal reconstruction after previous sternotomy in patients with a patent left internal thoracic artery graft is feasible and can be safely performed.

Primary cardiac sarcomas are rare but aggressive tumors and can present a technical challenge with regard to surgical approach and resection. Complete surgical resection, when feasible, remains crucial for palliation of symptoms and for its role as the mainstay of cardiac sarcoma therapy. Surgical resection of recurrent cardiac sarcomas, though formidable, is technically feasible and may provide reasonable survival, especially when the recurrence is local and the metastatic load is limited. In this case report, we describe a successful third cardiac sarcoma resection procedure in a young patient with previous cardiac autotransplantation and excision of left atrial sarcoma.