Journal of Cardiac Surgery最新文献

Objective. Proposing a novel arterial cannulation technique for acute DeBakey type I aortic dissection with severe aortic arch and branch involvement to enhance CPB effectiveness and reduce organ malperfusion complications. Methods. The technique involves retrograde insertion of an arterial perfusion tube into the aortic arch through the left common carotid artery. Extracorporeal circulation is established, and total aortic arch replacement with deep hypothermic systemic circulation and a frozen elephant trunk stent placement are performed to restore lower body perfusion. Results. Six patients with severe aortic arch and branch involvement underwent the new arterial cannulation technique. All patients had smooth postoperative recoveries without significant complications. Conclusion. The novel arterial cannulation technique shows promise in managing acute DeBakey type I aortic dissection with extensive vascular involvement, reducing complications, and enhancing patient outcomes. Further validation with a larger patient cohort is needed to confirm its effectiveness and safety. If successful, this technique could become a valuable addition to treatment strategies for improved outcomes.

Objective. The high recurrence rate of mitral regurgitation (MR) in patients with atrial functional mitral regurgitation (AFMR) who underwent mitral annuloplasty (MAP) is reported. However, the mechanism of recurrence is not fully understood and appropriate surgical intervention remains unknown. Herein, we reviewed patients with AFMR who underwent MAP at our institution and investigated the preoperative geometric characteristics of the mitral valve in terms of MR recurrence after surgery. Methods. We retrospectively evaluated 20 patients with AFMR who underwent MAP between 2010 and 2022. The mean follow-up period was 3.2 ± 2.3 years. Preoperative three-dimensional transesophageal echocardiography (3D TEE) was available for all patients, and geometric analysis of the mitral valve was performed using the Philips Q-Lab software. Results. MR recurred in six patients. The rates of freedom from MR recurrence were 79% and 57% at one and three years, respectively. The lateral portion of the posterior mitral leaflet (PML) in patients with recurrent MR was longer and thicker than that in patients without recurrent MR (length of P1; 10 ± 3 vs. 15 ± 5 mm, p < 0.01, length of P2; 11 ± 4 vs. 14 ± 4 mm, p = 0.23, length of P3; 8 ± 3 vs. 10 ± 3 mm, p = 0.13). Conclusions. Patients with remodeling of the lateral portion of PML tended to have recurrent MR after MAP. This factor could indicate progressive remodeling, and MAP alone may not be a sufficient intervention for these patients.

Introduction. The use of thyroid hormone supplementation (THS) for donor optimization has not been standardized and remains an area of academic investigation and clinical interest. The purpose of this study is to investigate the impact of THS supplementation on heart transplant recipient outcomes. Methods. Adult heart transplant recipients in the UNOS database recorded from January 1, 2000 to June 30, 2022 formed the study cohort. Simple comparisons were made with t-tests or chi-squared tests. Logistic regression models were used to predict 30 day and 1 year survival. Accelerated failure time models were employed to analyze time to death and time to rejection. Results. The cohort consisted of 46,542 heart transplants, of which 28,911 (62%) received THS prior to organ procurement. In adjusted models, donor THS was associated with a reduction of 11% in the odds of death within 30 days (OR = 0.89; p = 0.048); however, this relationship did not extend to one year post-transplant survival (OR = 1.00; p = 0.968). After a sex-based analysis, 30-day survival benefit was seen only in male-to-male donor-recipient pairings (OR for death = 0.82; p = 0.007). Overall survival and post-transplant rejection was also improved in the male-to-male group (HR = 0.94; p = 0.002 and HR = 0.96; p = 0.048) and the female-to-female group (HR = 0.87; p = 0.003 and HR = 0.90; p = 0.013). There was no associated survival benefit with THS in sex mismatched groups. Conclusion. THS in donors is associated with improved 30-day post-transplant survival and overall survival after OHT in sex-matched donor-recipient pairs. Further study is warranted.

Background. The morphology of the papillary muscles of the left ventricle is highly variable. Few studies have investigated papillary muscle morphology using imaging. Objective. This study aimed to assess papillary muscle morphology with primary mitral regurgitation (MR) using cardiac computed tomography (CT). Methods. We examined 116 patients who underwent robotic mitral valve repair for primary MR using preoperative cardiac CT. Papillary muscle morphology was assessed using CT images and compared with operative findings. Results. CT images of papillary muscles were consistent with the operative findings during robotic mitral valve repair in all cases. Both the anterolateral papillary muscle (APM) and posteromedial papillary muscle (PPM) groups were identified in all cases, and the middle papillary muscle (MPM) group was identified in 24.1% of cases. The PPM group had a higher proportion of complex morphologies with more heads and bases than the APM group (head: p < 0.001 and base: p < 0.001). The PPM group had smaller papillary muscle sizes than the APM group. The MPM group in most patients had one base and one head (78.6%). Papillary muscle sizes were significantly smaller in the order of the APM, PPM, and MPM groups (p < 0.001). Conclusions. Cardiac CT allowed clear visualization and accurate assessment of papillary muscle morphology in the left ventricle. It may be useful to obtain the papillary muscle variations preoperatively using CT imaging in procedures involving the papillary muscles such as mitral valve repair.

Background. The 2018 Organ Procurement and Transplantation Network (OPTN) heart allocation policy change prioritizes patients bridged to transplant with mechanical circulatory support (MCS) devices, including extracorporeal membrane oxygenation (ECMO). As a result, the use of ECMO has significantly increased. Methods. We reviewed the OPTN database for adult patients undergoing heart transplant after bridge with ECMO between January 1^st 2000 and October 18^th 2018. We excluded patients with ≥180 days of ECMO duration, prior transplants, and those using additional MCS devices. Survival and morbidity outcomes of patients with ≥7 days of pre-transplant ECMO were compared to those of patients with <7 days. Results. Of 362 eligible transplant recipients, 163 (45%) utilized <7 days of pre-transplant ECMO and 199 (55%) utilized ≥7 days. Those with ≥7 days were younger (median age: 43 [28–54] vs. 50 [36–57] years, p = 0.006) and more likely to have temporary waitlist inactivity (18% vs. 7%, p = 0.003) with significantly longer duration of ECMO use (median: 14 [9–24] vs. 4 [2–5] days, p  <  0.001). Patients with ≥7 days of ECMO had comparable survival to those with <7 days at one year (81.1% vs. 79.4%, p = 0.64) and five years (61.1% vs. 49.3%, p = 0.27). After adjustment for clinically relevant variables, duration of ECMO ≥7 days did not increase mortality at five years (HR = 0.90, p = 0.59). Conclusions. Longer duration of ECMO (≥7 days vs. <7 days) among patients successfully bridged to transplant is not associated with increased mortality or selected adverse outcome, including graft failure or rejection, at up to five years.

Objective. The adoption of transcatheter aortic valve replacement (TAVR) has changed the profile of patients referred for surgical aortic valve replacement (SAVR) and drawn more attention to valve sizing and durability. We examined the influence of TAVR on SAVR practice. Methods. Using a statewide database, we evaluated all isolated SAVRs, categorized into three eras: pre-TAVR (2008 to 2011), early TAVR (2012 to 2015), and current-TAVR (2016 to 2022). The primary outcomes of interest were changes in prosthetic valve size and the percentage of mechanical valves used between time periods. Results. There were 6,445 patients included. SAVR volume declined in the current era. Valve size increased over time. In the pre-TAVR era, 41% of patients received a valve smaller than 23 mm, which declined to 33% in the early TAVR era, then to 22% in the current era (p < 0.001 for all). The year of surgery was significantly associated with larger valve selection even after controlling for patient characteristics. Annular enlargement rose in the current-TAVR era (p < 0.001). The use of mechanical valves rose in the current era (p < 0.001 compared to early TAVR). Regression analysis showed that the year of surgery was not predictive of mechanical valve use, suggesting that changes in practice were driven by patient characteristics. Conclusion. Surgical valve choice since the adoption of TAVR has changed, with less frequent use of smaller valves. Increases in mechanical valve usage are likely a reflection of changing patient population.

Background. Multivessel coronary artery disease (CAD) and left ventricular dysfunction (LVD) present challenges in CABG. We aimed to compare early outcomes of total arterial revascularization (TAR) versus conventional CABG in this high-risk population. Methods. This was a retrospective cohort study based on a single-center registry of patients who underwent isolated CABG for multivessel CAD and LVD between January 2014 and December 2022. Primary outcome was in-hospital mortality. Secondary outcomes were early complications, graft patency rate at 3 months, readmission rate within 6 months, and freedom from angina rate within 6 months. Results. A total of 112 cases were included in this study; 52 patients for TAR and 60 patients for conventional CABG. Both groups had comparable baselines and operative profiles. In-hospital mortality was similar between TAR and conventional CABG (2 deaths, 3.85% vs 4 deaths, 6.67%, p = 0.810). TAR had shorter ICU (3.5 vs 5 days, p = 0.016) and hospital stay (10.5 vs 12 days, p = 0.007). Other postoperative complications were similar. At 3 months, TAR had superior graft patency (91.7% vs 83.7%, p = 0.034) and lower 6-month readmission (TAR: 2/50, 4.0% vs. CR: 10/56, 17.9%, p = 0.024). Freedom from angina rate within 6 months was similar between the two groups (TAR: 43/50, 86.0% vs. CR: 42/56, 75.0%, p = 0.240). Conclusion. Our findings suggest that TAR may offer benefits in terms of shorter hospital stays, higher early graft patency, and lower readmission rates for patients with multivessel CAD and LVD. However, further research, particularly large-scale, randomized trials with longer follow-up periods, are needed to fully understand the long-term clinical outcomes and confirm these promising early results.

Background and Aim of the Study. While several studies have suggested a relationship between adverse postoperative outcomes and systemic lupus erythematosus (SLE) in major surgical settings, no study to date has explored postoperative outcomes of SLE patients undergoing coronary artery bypass grafting (CABG). This study aimed to compare the characteristics and outcomes of SLE patients compared to non-SLE patients undergoing CABG. Methods. We utilized the Nationwide Inpatient Sample (NIS) data from 2008–2018 for CABG patients ≥18 years old. Patients were divided into two groups based on SLE status (confirmed SLE diagnosis or no SLE present). Primary outcomes were in-hospital mortality, favorable discharge, and length of stay (LOS). Secondary outcomes included acute kidney injury (AKI), acute liver injury (ALI), hemodialysis, acute myocardial infarction (AMI), and cardiogenic shock. Patient characteristics including age, sex, race, and preexisting comorbidities were considered. Multivariable models, adjusting for confounding variables, were utilized. Results. Data from a total of 352,772 patients who underwent CABG were analyzed. 980 patients had a diagnosis code for SLE. SLE and non-SLE patients had similar rates of in-hospital mortality (OR = 0.92, [0.63–1.35]), nonhome discharge (OR = 1.09, [0.95–1.24]), and LOS (OR = 1.02, [0.99–1.06]). SLE patients developed AKI at a higher rate (OR = 1.50, [1.05–1.48]) and ALI at a lower rate (OR = 0.35, [0.16–0.74]). Both groups had similar rates of hemodialysis (OR = 1.19, [0.98–1.44]), AMI (OR = 0.93, [0.81–1.06]), and cardiogenic shock (OR = 0.8, [0.61–1.05]). Conclusion. These findings suggest that SLE patients undergoing CABG have similar mortality, discharge disposition, and LOS compared to non-SLE patients. However, SLE patients are at increased risk of AKI and decreased risk of ALI than non-SLE patients. These associations warrant further investigation to elucidate their physiologic basis.

Objectives. Aortic coarctation in neonates remains a clinical challenge. Low weight, arch hypoplasia and ductal dependence have been identified as risk factors for recurrent coarctation. We hypothesized that a tailored surgical technique may prevent recurrence. Methods. Retrospective evaluation of neonates treated for coarctation through thoracotomy was done. No primary percutaneous procedure was performed and repairs through sternotomy were excluded. Aortic hypoplasia was defined as a ratio arch diameter (mm)/patient’s weight (kg) < 1. Extended end-to-end anastomosis (EEEA), subclavian flap (Waldhausen) and Amato aortoplasty were performed. Mortality and recurrent obstruction requiring re-intervention were assessed. Results. Records of 340 consecutive patients (2003–2019) were analyzed. Preoperative median age and weight were, respectively, 10 days (1–30) and 3080 grams (1400–5180). Arch hypoplasia was documented in 31 patients (9.1%). Prostaglandin was infused in 220 (65.3%). Critical preoperative status was documented in 35 (10.8%). EEEA repair was performed in 273 (80.3%), Waldhausen was performed in 42 (12.4%), and Amato was performed in 25 (7.4%). The last two were more likely to be performed in the presence of arch hypoplasia (p < 0.0001). Hospital mortality occurred in 2 patients (0.6%). Thirty-six procedures (31 percutaneous/5 surgical) were performed for recurrent arch obstruction in 33 patients. Three late deaths occurred. Low-weight, hypoplastic arch, and ductal dependency did not influence the outcome. All survivors were free from residual coarctation at a mean follow-up of 3.6 ± 3.4 years postoperatively. Conclusions. Surgical repair remains the procedure of choice for neonatal coarctation. A tailored approach using alternative techniques seemed to offer comparable results even in presence of associated risk factors.

Purpose. Minimally invasive mitral valve repair (MIMVR) has been demonstrated to be safe and effective, but technical difficulty, outcome variation, and lack of standardized protocols undermine the utility of artificial chordae. This study aims to analyze the midterm outcomes of repair using artificial chordae through right minithoracotomy. Methods. A retrospective cohort study was conducted on consecutive patients who underwent MIMVR using artificial chordae at a single center in Vietnam between April 2016 and April 2022. Valve repairs were separated into two groups based on a previously validated complexity score: simple repair (Group 1) and intermediate-to-complex repair (Group 2). Demographic variables, comorbidities, operative characteristics, surgical outcomes, and follow-up data on survival and mitral regurgitation (MR) grade were analyzed. The learning curve was assessed by comparing the number of procedures with operation time and aorta cross-clamp time. Primary endpoints included survival and freedom from recurrent MR at four years. Results. Ninety patients were identified, including 41 simple and 49 intermediate-to-complex repairs. The mean age was 50.5 ± 12.9 years. Both groups had similar preoperative characteristics. The perioperative and postoperative outcomes were favorable, with no cases requiring mitral valve replacement. The median follow-up time was 30.3 months (18.2–40.4), and there were two (2.2%) cardiac deaths, with one in each group. The Kaplan–Meier survival estimates for Groups 1 and 2 at 12 and 24 months were 97% vs. 100% and 97% vs. 96%, respectively (95% CI = 0.05–12.2, P = 0.850), and estimates for freedom from recurrent MR were 97% vs. 92% and 97% vs. 88%, respectively (95% CI = 0.49–12.0, P = 0.260). There was a negative association between the volume of operations and the duration of operation and aortic cross-clamp time, leading to shorter durations. Conclusion. Based on our single-center experience, MIMVR using artificial chordae via right mini-thoracotomy can be safely and effectively performed in resource-limited countries for patients with MR. This approach has been shown to be applicable for a range of MR complexities, from simple to intermediate-to-complex MV repairs, and has demonstrated promising results in terms of midterm freedom from MR recurrence.