Faculty Bibliography

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)

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.

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.

BACKGROUND: Bundled Payments for Care Improvement (BPCI) initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. Payment model 2 reimburses based on a target price for 90-day episode of care postprocedure. The challenge for valve patients is the historically high (>35%) 90-day readmission rate. We analyzed our institutional cardiac surgical service line adaptation to this initiative. METHODS: On May 1, 2015, we instituted a readmission reduction initiative (RRI) that included presurgical risk stratification, comprehensive predischarge planning, and standardized postdischarge management led by cardiac nurse practitioners (CNPs) who attempt to guide any postdischarge encounters (PDEs). A prospective database also was developed, accruing data on all cardiac surgery patients discharged after RRI initiation. We analyzed detailed PDEs for all valve patients with complete 30-day follow-up through November 2015. RESULTS: Patients included 219 surgical patients and 126 transcatheter patients. Sixty-four patients had 79 PDEs. Of these 79 PDEs, 46 (58.2%) were guided by CNPs. PDEs were due to fluid overload/effusion (21, 27%), arrhythmia (17, 22%), bleeding/thromboembolic events (13, 16%), and falls/somatic complaints (12, 15%). Thirty-day readmission rate was 10.1% (35/345). Patients with transcatheter aortic valve replacement had a higher rate of readmission than surgical patients (15.0% vs 6.9%), but were older with more comorbidities. The median readmission length of stay was 2.0 days (interquartile range 1.0-5.0 days). Compared with 2014, the 30-day readmission rate for BPCI decreased from 18% (44/248) to 11% (20/175), P = .05. CONCLUSIONS: Our reengineering of pre/postdischarge management of BPCI valve patients under tight CNP control has significantly reduced costly 30-day readmissions in this high-risk population.

AIM: To compare the economic value of EDWARDS INTUITY Elite (EIE) valve system for rapid-deployment aortic valve replacement (RDAVR) in a full sternotomy (FS) approach (EIE-FS-RDAVR) versus FS-AVR using conventional stented bioprosthesis. DATA & METHODS: A simulation model to compare each treatment's 30-day inpatient utilization and complication rates utilized: clinical end points obtained from the TRANSFORM trial patient subset (EIE-FS-RDAVR) and a best evidence review of the published literature (FS-AVR); and costs from the Premier database and published literature. RESULTS: EIE-FS-RDAVR costs $800 less than FS-AVR per surgery episode attributable to lowered complication rates and utilization. Combined with the lower mortality, EIE-FS-RDAVR was a superior (dominant) technology versus FS-AVR. CONCLUSION: This preliminary investigation of EIE-FS-RDAVR versus conventional FS-AVR found the EIE valve offered superior economic value over a 30-day period. Real-world analyses with additional long-term follow-up are needed to evaluate if this result can be replicated over a longer timeframe.