Faculty Bibliography

OBJECTIVE:Medicare's Bundle Payment for Care Improvement(BPCI) Model 2 groups reimbursement for valve surgery into 90-day episodes of care(EOC) which include operative costs, inpatient stay, physician fees, post-acute care, and readmissions up to 90 days post-procedure. We analyzed our BPCI patients' 90-day outcomes to understand the late financial risks and implications of the bundle payment system for valve patients. METHODS:All BPCI valve patients from 10/2013 (start of risk-sharing phase) through 12/2015 were included. Readmissions were categorized as early (≤30 days) or late (31-90 days). Data were collected from institutional databases as well as Medicare claims. RESULTS:Analysis included 376 BPCI valve patients: 202 open and 174 transcatheter aortic valves (TAVR). TAVR patients were older (83.6 vs 73.8 years; p=0.001) and had higher STS predicted risk (7.1% vs 2.8%; p=0.001). Overall, 18.6% of patients (70/376) had one-or-more 90-day readmission, and total claims was on average 51% greater for these patients. Overall readmissions were more common among TAVR patients (22.4%(39/174) vs 15.3%(31/202),p=0.052) as was late readmission. TAVR patients had significantly higher late readmission claims, and early readmission was predictive of late readmission for TAVR patients only (p=0.04). CONCLUSION/CONCLUSIONS:Bundled claims for a 90-day episode of care are significantly increased in patients with readmissions. TAVR patients represent a high-risk group for late readmission, possibly a reflection of their chronic disease processes. Being able to identify patients at highest risk for 90-day readmission and the associated claims will be valuable as we enter into risk-bearing EOC agreements with Medicare.

AIM/OBJECTIVE:To estimate undiagnosed aortic stenosis (AS) in the Medicare population. METHODS:Patients enrolled (2011-2014) were eligible. After criteria were applied, time zero was the first record of an echocardiogram (ECHO) for the ECHO-AS cohort and randomly assigned for the no-ECHO cohort. The ECHO-AS cohort was propensity matched to patients in the no-ECHO cohort, and survival analysis was performed. RESULTS: Of the 854,493 (25%) patients who received an ECHO, 1 in 4 were diagnosed with AS. After propensity matching, the no-ECHO cohort who died, almost half (49%) had a record of a cardiovascular event prior to their death. The no-ECHO cohort had statistically significant (p = 0.003) higher risk of death than their ECHO-AS counterparts. CONCLUSION/CONCLUSIONS:In the Medicare population, patients aged 65 years or older, with increased risk factors for and symptoms common in AS patients, should be considered for diagnostic ECHOs.

Objective: A 63-year-old man with severe asymmetric pectus excavatum (Haller index 3.55) presented with New York Heart Association class I symptoms, severe mitral regurgitation due to flail posterior leaflet, and preserved left ventricular (LV) function. Our goalwas to demonstrate a totally endoscopic robotic-assisted mitral repair.
Patient(s): Intraoperative transesophageal echocardiography confirmed severe mitral regurgitation with an anteriorly directed jet due to prolapse of the middle scallop of the posterior leaflet. Four ports were placed in the right chest for the da Vinci Xi surgical system (working, camera, left and right instruments), and cardiopulmonary bypass was instituted via femoral access with arterial and long venous cannulae. While preparing the pericardium, we noted that the right pulmonary veins entered the left atrium leftward of the sternum. An endoclamp was positioned with fluorescent guidance, and antegrade Del Nido cardioplegia was administered. Sondergaard's groove was opened and the left atrial appendage was oversewn with 2 layers of polytetrafluoroethylene sutures. With intracorporeal guidance, a 5th port for an atrial retractor was positioned to the right of the sternum, verifying that it could reach deep enough into the left chest. Analysis of lesions demonstrated a flail P2 leaflet and a globally myxoid mitral valve consistent with Barlow's disease. Although a 0-angle scope provided sufficient visualization of the valve and subvalvular regions, intermittent conflict existed between the instruments and the posterior sternum. A triangular excision of P2 was performed; abnormal chordae were excised below P2, and the defect was closed with polytetrafluoroethylene sutures. A 36-mm posterior annuloplasty band was attached with interrupted 2-0 braided sutures, and hydrostatic testing revealed no residual regurgitation.While the patient was being rewarmed, the endoclamp balloon was deflated while the LV and root were vented. The heart spontaneously returned to sinus rhythm, and the patient was weaned from cardiopulmonary bypass without inotropic support. Postoperative transesophageal echocardiography demonstrated preserved LV function and no residual regurgitation or gradient. The patient was extubated in the operating room and discharged on postoperative day 2.
Conclusion(s): Severe pectus excavatum can make right chest approaches difficult, even in a totally endoscopic robotic approach, but the lack of chest wall disruption allows a speedy recovery

Objective: A 75-year-old woman with New York Heart Association class II heart failure presented with severe mitral and tricuspid regurgitation. Eight years prior, the patient had a large right thoracotomy for resection of a pleural tumor. Our goal was to demonstrate a totally endoscopic resection of an unsuspected recurrent pleural tumor preceding concomitant mitral and tricuspid valve repair.
Method(s): After initially positioning the patient in the left decubitus position via a posterolateral approach, extensive adhesiolysis between the right lower lobe and the diaphragmrevealed a nonimaged 2- to 3-cmmass in the right lower lobe. Limited parenchymal resection was performed. The patient was repositioned in a supine position. Transesophageal echocardiography confirmed severe mitral regurgitation with moderate to severe tricuspid regurgitation. Five lateral thoracic ports were placed for the da Vinci Xi system. Cardiopulmonary bypass was instituted via femoral access with independent femoral and internal jugular venous lines. An endoballoon clamp was positioned with fluorescent guidance and antegrade del Nido cardioplegia was administered. Sondergaard's groove was opened, and the left atrial appendage was oversewn with 2 layers of polytetrafluoroethylene (PTFE) sutures. The mitral valve was nonmyxoid, inconsistent with Barlow's disease. Inspection confirmed mild prolapse of the anterior leaflet, numerous hypertrophied and calcified secondary chordae, and restriction of the posterior leaflet. Secondary chordae were excised below the A2-A3, P1-P2, and P2-P3 clefts. Small triangular excisions were performed at the A2-A3 and P1-P2 junctions, which were both reconstructed with a running PTFE suture. Hydrostatic testing revealed mild central insufficiency due to a lack of coaptation depth. Commissuroplasty was performed with a single PTFE suture, and the P2-P3 cleft was closed with a running PTFE suture. A 30-mmannuloplasty band was inserted. Final hydrostatic testing revealed excellent leaflet coaptation. The cavae were occluded with snares, and the tricuspid valve was exposed via a right atriotomy. A reduction tricuspid annuloplasty with a 26-mm band was performed. With the heart reperfused and the aortic root and left ventricle vented, the atriotomies were closed.
Result(s): Postoperative transesophageal echocardiography demonstrated preserved left ventricular function with trace mitral and tricuspid regurgitation. The patient was discharged on postoperative day 6. Final pathological analysis confirmed a completely resected benign solitary fibrous tumor.
Conclusion(s): A totally endoscopic approach to mitral and tricuspid valve repair can be performed safely and effectively in patients with a prior right thoracotomy

BACKGROUND:Expandable, rapid deployment aortic valves may interfere with the cardiac conduction system, which can lead to permanent pacemaker implantation (PPI). We sought to characterize PPI following rapid deployment aortic valve replacement (RDAVR) with the EDWARDS INTUITY valve system and investigate associated factors. METHODS:We analyzed 708 patients from 29 centers in the TRANSFORM trial undergoing RDAVR ± CABG without pre-existing pacemakers. Intrinsic conduction status was recorded as well as PPI incidence through one year. PPI indications were categorized based on expert review of patient PPI source documents. Multi-variate analysis was conducted to identify characteristics associated with PPI. RESULTS:among the largest enrolling centers. CONCLUSIONS:Patient factors associated with PPI after RDAVR were RBBB, AVB, female gender and larger valve size. Interestingly, a strong center-level effect was associated with PPI. This effect may reflect differences in practice patterns, such as postoperative drug management or timing to PPI. These findings provide a deeper understanding of PPI after RDAVR and help guide clinical practice and patient management.

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.