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)

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.

OBJECTIVE: In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates. METHODS: Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4-0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm. RESULTS: Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow. CONCLUSIONS: We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.

We describe the use of the Sapien XT, placed in the mitral position using a totally endoscopic robotic approach in a 76-year-old man with extensive circumferential mitral calcifications and severe stenosis. The patient was at high risk for traditional open surgery and a large mitral valve annulus prevented safe transcatheter deployment due to size mismatch. Our novel approach offered a minimally invasive technique for native mitral valve replacement in a high-risk patient with anatomical constraints prohibitive to conventional approaches. doi: 10.1111/jocs.12737 (J Card Surg 2016;31:303-305).

OBJECTIVE: The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesia in patients undergoing robotic mitral valve repair. DESIGN: A randomized, prospective trial. SETTING: A single tertiary referral academic medical center. PARTICIPANTS: 60 patients undergoing robotic mitral valve surgery. INTERVENTIONS: Patients were randomized to receive 4-level paravertebral blockade with 0.5% bupivicaine before induction of general anesthesia. All patients were given a fentanyl patient-controlled analgesia upon arrival to the intensive care unit, and visual analog scale pain scores were queried for 24 hours. On postoperative day 2, patients were given an anesthesia satisfaction survey. MEASUREMENTS AND MAIN RESULTS: After obtaining institutional review board approval, surgical and anesthetic data were recorded perioperatively and compared between groups. Compared to general anesthesia alone, patients receiving paravertebral blockade and general anesthesia reported significantly less postoperative pain and required fewer narcotics intraoperatively and postoperatively. Patients receiving paravertebral blockade also reported significantly higher satisfaction with anesthesia. Successful extubation in the operating room at the conclusion of surgery was 90% and similar in both groups. Hospital length of stay also was similar. No adverse reactions were reported. CONCLUSIONS: The addition of paravertebral blockade to general anesthesia appears safe and can reduce postoperative pain and narcotic usage in patients undergoing minimally invasive cardiac surgery. These findings were similar to previous studies of patients undergoing thoracic procedures. Paravertebral blockade alone likely does not reduce hospital length of stay. This may be more closely related to early extubation, which is possible with or without paravertebral blockade.

OBJECTIVE: Immediate extubation of select patients in the operating room after cardiac surgery has been shown to be safe and may result in improved hemodynamics and decreased cost perioperatively. The aim of this study was to evaluate whether the addition of paravertebral blockade (PVB) to general anesthesia facilitates extubation in the operating room in patients undergoing totally endoscopic robotic mitral valve repair (TERMR). METHODS: A review of 65 consecutive patients who underwent TERMR between January 2012 and June 2013 at a single institution was conducted. Patients were divided into two groups, one group that received PVB and general anesthesia and a second group that received general anesthesia alone. The data analyzed included quantities of anesthetic administered during surgery and the location of extubation after surgery. RESULTS: A total of 34 patients received PVB and general anesthesia, whereas 31 received general anesthesia alone. The two groups had similar demographic and surgical data. Patients in the PVB and general anesthesia group were more likely to be extubated in the operating room (67.6%, n = 23 vs 41.9%, n = 13, P = 0.048) and required less intraoperative fentanyl (3.41 mug/kg vs 4.90 mug/kg, P = 0.006). There were no adverse perioperative events in either group related to PVB or extubation. CONCLUSIONS: The addition of PVB to general anesthesia for perioperative pain control facilitated extubation in the operating room in patients undergoing TERMR. Paravertebral blockade allowed for lower intraoperative fentanyl dosing, which may account for the increased incidence of immediate extubation. A detailed prospective study is warranted.