Faculty Bibliography

OBJECTIVE:The optimal management of mitral regurgitation (MR) in patients with cardiomyopathy has been controversial. Minimally invasive fibrillating mitral valve replacement (mini-MVR) might limit postoperative morbidity and mortality by minimizing recurrent MR. We hypothesized that mini-MVR with complete chordal sparing would offer low mortality and halt left ventricular (LV) remodeling in patients with severe cardiomyopathy and severe MR. METHODS:From January 2006 to August 2009, 65 patients with an LV ejection fraction (LVEF) of ≤35% underwent mini-MVR. The demographic, echocardiographic, and clinical outcomes were analyzed. RESULTS:The operative mortality compared with the Society of Thoracic Surgeons-predicted mortality was 6.2% versus 6.6%. It was 5.6% versus 7.4% for patients with an LVEF of ≤20% and 8.3% versus 17.9% among patients with a Society of Thoracic Surgeons-predicted mortality of ≥10%. At a median follow-up of 17 months, no recurrent MR or change in the LV dimensions or LVEF had developed, but the right ventricular systolic pressure had decreased (P=.02). At the first postoperative visit and latest follow-up visit, the New York Heart Association class had decreased from 3.0±0.6 to 1.7±0.7 and 2.0±1.0, respectively (P<.0001 for both). Patients with an LVEF of ≤20% and LV end-diastolic diameter of ≥6.5 cm were more likely to meet a composite of death, transplantation, or LV assist device insertion (P=.046). CONCLUSIONS:Our results have shown that mini-MVR is safe in patients with advanced cardiomyopathy and resulted in no recurrent MR, stabilization of the LVEF and LV dimensions, and a decrease in right ventricular systolic pressure. This mini-MVR technique can be used to address severe MR in patients with advanced cardiomyopathy.

OBJECTIVE:Reoperative aortic valve replacement (re-AVR) in octogenarians is considered high risk and therefore might be indicated for transcatheter AVR. The minimally invasive technique for re-AVR limits dissection and might benefit this patient population. We report the outcomes of re-AVR in high-risk octogenarians who might be considered candidates for transcatheter AVR to assess the safety of re-AVR and minimally invasive operative techniques. METHODS:We identified 105 patients, aged ≥80 years, who underwent open re-AVR at our institution from July 1997 to December 2011. Patients requiring concomitant coronary bypass surgery and/or other valve surgery were excluded. The outcomes of interest included operative mortality, postoperative complications, and midterm postoperative survival. RESULTS:Of the 105 patients, 51 underwent minimally re-AVR through upper hemisternotomy (Mre-AVR) and 54 standard full sternotomy (Fre-AVR). The mean patient age was 82.8 ± 3.8 years. No significant differences were found in the patient risk factors. Postoperatively, 6 patients (5.7%) underwent reoperation for bleeding, 4 (3.8%) experienced permanent stroke, 4 (3.8%) developed new renal failure, and 22 (21.0%) had new-onset atrial fibrillation. Overall, the operative mortality was 6.7%, and the 1- and 5-year survival was 87% and 53%, respectively. When Mre-AVR and Fre-AVR were compared, the operative mortality was 9.2% in the Fre-AVR group and 3.9% in the Mre-AVR group (P = .438). Kaplan-Meier analysis showed a survival benefit at both 1 year (79% ± 11.7% vs 92% ± 7.8%) and 5 years (38% ± 17.6% vs 65% ± 15.7%, P = .028) favoring Mre-AVR. Cox regression analysis identified heparin-induced thrombocytopenia, reoperation for bleeding, older age, full sternotomy, and an infectious complication as predictors of mortality. CONCLUSIONS:Octogenarians who undergo re-AVR are thought to be high-risk surgical candidates. The present single-center series revealed acceptable in-hospital outcomes and operative mortality. Mre-AVR was associated with better survival compared with Fre-AVR and might benefit this population.

Valve endocarditis is associated with high morbidity and mortality and requires a thorough evaluation including early surgical consultation to identify patients who may benefit from surgery. We review 5 recent articles that highlight the current debates related to best treatment strategies for valve endocarditis. Recent publications have focused on neurologic risk assessment, timing of surgery, and prognostic factors associated with native and prosthetic valve endocarditis. The initial patient assessment and management is best performed by a multidisciplinary team. Future investigations should focus on identifying surgical candidates early and the outcomes affected by replacement valve choice in both native and prosthetic valve endocarditis.

OBJECTIVE:Different cerebral protection strategies are currently being practiced during noncomplex hemiarch surgery without randomized control studies to show their relative efficacy. We hypothesized that deep hypothermic circulatory arrest (DHCA) alone was adequate for cerebral protection in noncomplex hemiarch surgery. METHODS:Four hundred sixty-seven patients underwent noncomplex hemiarch surgery between January 2002 and December 2012. Calcified aortas and total arch surgeries were excluded. DHCA alone was used for 276 patients, DHCA with antegrade cerebral perfusion (ACP) was used for 114 patients, and DHCA with retrograde cerebral perfusion (RCP) was used for 77 patients. RESULTS:Preoperative characteristics were similar between groups (12.3% in the DHCA group, 12.3% in the ACP group, and 10.3% in RCP group were reoperations). Patients in the DHCA group had shorter cardiopulmonary bypass times (193 minutes vs 217 minutes; P ≤ .005) and total lower body ischemic times (21 minutes vs 30 minutes; P ≤ .001) than ACP, but not RCP. Rates of reoperations for bleeding, postoperative stroke, and new renal failure did not differ between groups. New onset of cerebrovascular events were seen in 5.4% of patients in the DHCA group versus 6.2% of patients in the ACP group and 6.4% of patients in the RCP group (all P values > .7). Operative mortality in the DHCA group was 4.7% versus 2.6% in the ACP group and 2.6% in the RCP group (all P values > .4). Cox proportional hazard modeling showed no survival differences between groups. CONCLUSIONS:Outcomes and survival using DHCA alone were comparable to adjunct cerebral protection methods in patients undergoing noncomplex hemiarch surgery. DHCA alone is as safe as other adjunct complex cerebral protection techniques and simplifies operation without additional risk.

OBJECTIVE:The optimal treatment of multivessel coronary artery disease is not well established. Hybrid coronary revascularization by combining the left internal mammary artery-left anterior descending artery graft and drug-eluting stents in non-left anterior descending artery territories might offer superior results compared with sole coronary artery bypass grafting or sole percutaneous coronary intervention. METHODS:We retrospectively analyzed the 30-day outcomes of 381 consecutive patients undergoing coronary artery bypass grafting (n = 301) vs hybrid coronary revascularization (n = 80). In a 2 × 2 matrix, the 2 groups were stratified by the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (≤32 vs ≥33) and the European System for Cardiac Operative Risk Evaluation (euroSCORE) (<5 vs ≥5). The composite endpoint (death from any cause, stroke, myocardial infarction, low cardiac output syndrome) and secondary endpoints (worsening postprocedural renal function and bleeding) were determined. RESULTS:After stratification using the SYNTAX and the euroSCORE, the preoperative characteristics were similar within the 4 groups, except for the ≥33 SYNTAX/>5 euroSCORE. The hybrid coronary revascularization patients were older (77 vs 65 years, P = .001). The postoperative outcomes using combined SYNTAX and the euroSCORE stratification showed a similar rate of the composite endpoint for all groups except for patients with ≥33 SYNTAX/>5 euroSCORE (0% for the coronary artery bypass grafting group vs 33% for the hybrid coronary revascularization group, P = .001). An analysis of the secondary endpoint showed similar results across all groups, except for in the ≥33 SYNTAX/>5 euroSCORE group, in which bleeding (re-exploration for bleeding and transfusion >3 packed red blood cell units per patient) was 44% in the hybrid coronary revascularization group vs 11% in the coronary artery bypass grafting group (P = .05). CONCLUSIONS:Hybrid coronary revascularization is a safe alternative to coronary artery bypass grafting in many patients with multivessel coronary artery disease. However, in high-risk patients with complex coronary artery disease (≥33 SYNTAX/>5 euroSCORE), coronary artery bypass grafting is superior to hybrid coronary revascularization.

OBJECTIVE:Axillary intra-aortic balloon pump therapy has been described as a bridge to transplant. Advantages over femoral intra-aortic balloon pump therapy include reduced incidence of infection and enhanced patient mobility. We identified the patients who would benefit most from this therapy while awaiting heart transplantation. METHODS:We conducted a single-center, retrospective observational study to evaluate outcomes from axillary intra-aortic balloon pump therapy. These included hemodynamic parameters, duration of support, and success in bridging to transplant. We selected patients on the basis of history of sternotomy, elevated panel-reactive antibody, and small body habitus. Patients were made to ambulate aggressively beginning on postoperative day 1. RESULTS:Between September 2007 and September 2010, 18 patients underwent axillary intra-aortic balloon pump therapy. All patients had the devices placed through the left axillary artery with a Hemashield side graft (Boston Scientific, Natick, Mass). Before axillary placement, patients underwent femoral placement to demonstrate hemodynamic benefit. Duration of support ranged from 5 to 63 days (median = 19 days). There was marked improvement in ambulatory potential and hemodynamic parameters, with minimal blood transfusion requirements. There were no device-related infections. Some 72% of the patients (13/18) were successfully bridged to transplantation. CONCLUSIONS:Axillary intra-aortic balloon pump therapy provides excellent support for selected patients as a bridge to transplant. The majority of the patients were successfully bridged to transplant and discharged. Although this therapy has been described in previous studies, this is the largest series to incorporate a regimen of aggressive ambulation with daily measurements of distances walked.

Marking human saphenous vein graft (HSV) with a surgical skin marker to prevent twisting on implantation is a common practice in peripheral and coronary artery bypass procedures. This study is designed to examine the effects of surgical skin markers on the HSV smooth muscle and endothelial functional responses. De-identified HSV remnants were collected during peripheral and coronary artery bypass procedures. Physiologic responses of the HSV were measured using a muscle bath. Veins that were marked with surgical skin markers intraoperatively generated significantly less contractile force to depolarizing KCl (110 mM) and receptor-mediated contractile agonists than unmarked HSV, suggesting that surgical skin markers impaired HSV smooth muscle contractility. To directly access the effects of chemical components in the surgical skin markers, unmarked HSV was exposed to isopropyl alcohol (a solvent commonly used in surgical skin markers) or methylene blue (a dye). Smooth muscle contractility was significantly reduced by isopropyl alcohol and methylene blue. Endothelial-dependent relaxation to carbachol was significantly reduced after exposure to surgical skin markers. Our data demonstrated that marking HSV with surgical skin markers reduces smooth muscle and endothelial functional viability.

BACKGROUND:The benefits of a minimally invasive approach to off-pump coronary artery bypass remain controversial. The value of completion arteriography in validating this technique has not been investigated. METHODS:From April 2007 to October 2009, fifty-six patients underwent isolated minimally invasive coronary artery bypass grafting through a left thoracotomy without cardiopulmonary bypass. Forty-three of these patients underwent completion arteriography. RESULTS:Sixty-five grafts were performed in these 56 patients, (average, 1.2 grafts per patient; range, 1 to 3). Forty-eight grafts were studied in the 43 patients undergoing completion arteriography. There were 4 findings on arteriogram leading to further immediate intervention (8.3%). These included 3 grafts with anastomotic stenoses or spasm requiring stent placement, and 1 patient who had limited dissection in the left internal mammary artery graft and underwent placement of an additional vein graft. These findings were independent of electrocardiographic changes or hemodynamic instability. The remainder of the studies showed no significant abnormalities. There were no deaths. One patient who did not have a completion arteriogram suffered a postoperative myocardial infarction requiring stent placement for anastomotic stenosis. Patients were discharged home an average of 6.8 days postoperatively. There were no instances of renal dysfunction postoperatively attributable to catheterization. CONCLUSIONS:Minimally invasive coronary artery bypass is safe and effective. Findings of completion arteriography occasionally reveal previously under-recognized findings that, if corrected in a timely fashion, could potentially impact graft patency and clinical outcomes. Our experience validates this minimally invasive technique.

OBJECTIVES/OBJECTIVE:We propose a simplified anatomic classification for pulmonary emboli that algorithmically differentiates those who might be best treated with surgical pulmonary embolectomy (type A) from those best treated medically (type B). We hypothesized that patients with type A pulmonary emboli treated with immediate surgical embolectomy demonstrate superior long-term survival compared with patients with type A pulmonary emboli treated medically. METHODS:Patients admitted between 2002 and 2008 with a diagnosis of pulmonary emboli made based on computed tomographic angiographic imaging (n = 779) were analyzed. Computed tomographic angiographic images were reviewed in a blind fashion, and anatomic classification of emboli was made. Patients with central thrombus, defined by location medial to the lateral mediastinal boundaries (ie, involving the main, primary, or both branch pulmonary arteries), were classified as having type A pulmonary emboli (n = 107), whereas those with peripheral pulmonary emboli located beyond these boundaries were classified as having type B pulmonary emboli (n = 672). Four patients with type A pulmonary emboli treated with catheter embolectomy were excluded from the analysis. RESULTS:Of the 103 patients with type A pulmonary emboli, 15 (14%) were treated with immediate surgical pulmonary embolectomy, and 88 (85%) were treated medically. Patients with type A pulmonary emboli treated surgically had similar 30-day mortality compared with those treated medically (13% vs 17%, P = .532). At a mean of 24 ± 18 months' follow-up (range, 1-82 months), survival at 1, 3, and 5 years for patients with type A pulmonary emboli treated surgically was significantly better than that in the patients with type A pulmonary emboli treated medically (P = .0001). CONCLUSIONS:For patients with type A pulmonary emboli, immediate surgical intervention appears to offer superior midterm survival compared with medical treatment alone. Although the medical and surgical groups were substantially different and the differences might have affected survival, this simplified classification for pulmonary emboli might help direct optimal treatment strategies.