Journal of Cardiac Surgery最新文献

Background. Current data reveal a predominace of left as opposed to right-sided cerebral strokes after transcatether aortic valve replacement (TAVR). Aortic arch variations might raise the likelihood of cardioembolic particles entering predominantly the left cerebral circulation during catheter tracking and manipulation. Aim. We sought to analyse the impact of aortic arch anatomy on stroke laterality (right vs. left) in patients undergoing TAVR. Methods. All patients who developed a symptomatic, periprocedural left- or right-sided ischemic stroke after TAVR between June 2007 and August 2022 were included in this study. Multislice computed tomography (MSCT) analysis was used to assess aortic arch anatomy, arch configuration (types I–III), arch tortuosity, and the determination of the take-off angles of the supraaortic arteries. Results. The final study cohort comprised 77 patients. Periprocedural ischemic stroke was left-sided in 66.2% of the patients (n = 51) and right-sided in 33.8% (n = 26) (p = 0.006). MSCT analysis revealed a standard aortic arch branching pattern in 70.1% (n = 54) and a common origin of the brachiocephalic and left common arteries (bovine arch anatomy) in 29.9% (n = 23) of the patients. There was no association between the anatomical variations of the aortic arch and stroke laterality (p = 0.601). Frequency of arch configuration types was 15.6% (type I), 74.0% (type II), and 10.4% (type III). There was no correlation between the different types of configuration and the laterality of periprocedural stroke (type I: p = 0.526, type II: p = 0.585, and type III: p = 1.000). Aortic arch tortuosity and angulation of the supraaortic arteries did also not differ between right- and left-sided strokes. Conclusion. Our data add evidence that there is a significant propensity for left-hemispheric strokes in patients undergoing TAVR. However, MSCT analysis in our cohort did not reveal an association between aortic arch geometry and laterality of stroke.

Background and Aim of Study.To evaluate predictors of residual left ventricular hypertrophy (LVH) one year after surgical aortic valve replacement (SAVR) in patients with aortic stenosis and clarify the relationship between long-term outcomes and predictors. Methods. We retrospectively reviewed 141 patients who underwent SAVR with a bioprosthetic valve. Left ventricular dimensions and mass index were assessed using serial transthoracic echocardiography. The difference in time course and the pattern of left ventricular mass index (LVMI) regression between patients with and without residual LVH one year after surgery were evaluated. The factors associated with LVMI one year after SAVR and the prognostic impact of these predictors on long-term outcomes were analyzed. Results. Although LVMI one year after surgery showed a significant decrease in patients with and without LVH, greater preoperative LVMI and lesser extent of LVMI decrease resulted in high residual LVMI at one year after SAVR in patients with LVH. The preoperative left ventricular end-diastolic dimension index (p = 0.027) and preoperative left atrial dimension (p = 0.001) were significant determinants of LVMI at one year after SAVR. A cut-off value of 30 mm/m² or greater for the left ventricular end-diastolic dimension index was optimal for predicting high LVMI one year after SAVR. Overall survival was significantly lower with a left ventricular end-diastolic dimension index ≥30 mm/m² (p = 0.017, Log rank). Conclusions. High preoperative left ventricular end-diastolic dimension index and large left atrial dimension were associated with high LVMI one year after surgical aortic valve replacement. Preoperative left ventricular end-diastolic dimension index of >30 mm/m² could predict adverse outcomes after surgical aortic valve replacement.

Background. Total sternotomy for aortic valve replacement has been superseded by less invasive approaches such as mini-sternotomy or transcatheter procedures. There has been an exponential uptake in transcatheter aortic valve implantation (TAVI) in younger and lower risk patients following recent randomized trials. This study aims to compare the outcomes of patients with aortic stenosis treated with minimally invasive approaches: mini-sternotomy for aortic valve replacement (mini-AVR) and TAVI implantation. Methods. Between January 2015 and December 2021, a total of 1437 TAVI and 176 mini-AVR patients from 2 tertiary centers fulfilled the criteria and were included in the propensity matching model. Results. A total of 256 TAVIs and 146 mini-AVR were included in the matched cohort. There was no significant difference in 30-day mortality in the two groups (TAVI vs. mini-AVR 2.7% vs. 2.8%, p = 0.935). TAVI confers slightly lower gradients in the follow-up echo when compared with mini-AVR (peak gradient 20 ± 8.7 mmHg vs. 24.5 ± 10 mmHg, p  < 0.001; mean gradient 10.9 ± 5.6 mmHg vs. 13.2 ± 5.7 mmHg, p < 0.001). On the other hand, mini-AVR exhibits remarkably lower rates of paravalvular leak (mild leak 8% vs. 41.5%, p < 0.001; moderate leak 2.8% vs. 0%, p < 0.001) and of need for permanent pacemaker implantation (2% vs. 12.2%, p < 0.001). Unsurprisingly, TAVI has lower in-hospital stay 3 (2 to 6) days vs. 10 (8 to 13) days, p < 0.001). Conclusions. For eligible aortic stenosis patients in the 7th decade of life, mini-AVR remains an excellent therapeutic option.

Background. The Perceval S is a sutureless, bovine pericardial aortic prosthesis on a nitinol stent, which has limited data on outcomes, as well as cost, from the United States. Methods. We performed a retrospective review of Perceval S implantation at a single center between 2015 and 2018. After exclusion criteria, we compared 234 patients who underwent sutureless aortic valve (SLV) implantation with 370 patients who underwent standard sutured aortic valves (SAVR). Hospital cost data were reviewed, and risk adjustment, done by propensity score and inverse probability weighting, was used to compare outcomes. Results. Compared to those undergoing SAVR, the SLV group was older and had a higher proportion of multicomponent operations, higher preoperative white blood cell count, higher rate of previous percutaneous coronary interventions, more comorbid conditions (diabetes, renal insufficiency, and dialysis), and more three-vessel coronary disease. For isolated AVR, partial upper hemisternotomy was more frequent in SLV. The mean cardiopulmonary bypass and cross-clamp times for isolated SLV were significantly lower than SAVR. After adjustment, the cohort was balanced. Operative differences for SLV were lower cross-clamp and pump time, larger valve size, more minimally invasive approaches, and shorter operating room times. There were no differences in other postoperative complications (postoperative atrial fibrillation, stroke, renal failure, prolonged ventilation, and in-hospital mortality; p > 0.05 for all). Mean and median hospital costs were higher in the SLV group, largely due to the cost of the implant. Conclusion. Sutureless tissue aortic valves can be used safely with lower cardiopulmonary bypass and clamp times than sutured prostheses and facilitate use of minimally invasive approaches. This valve may be advantageous in older, higher risk patients requiring more complex operations.

We introduce a unique perfusion method for open descending aortic repair through a left thoracotomy. Perfusion from femoral artery cannulation is generally adopted in descending aortic replacement surgery. However, in cases with shaggy or partially thrombosed chronic aortic dissection, retrograde perfusion alone has a high risk of embolization and alternative perfusion methods should be considered. Our perfusion method from the third part of the left axillary artery graft is safe, simple, and useful for avoiding postoperative cerebral complications. In the present study, we report the advantages and challenges of this graft-interposed perfusion via the distal left axillary artery for descending aortic replacement.

Background. Intraoperative team turnover is necessary given the duration of many cardiac surgical procedures, despite being an established risk factor for harm. We sought to determine if there was an association between intraoperative anesthesia handoff (AH) and patient morbidity and/or mortality after cardiac surgery. Methods. All adult cardiac surgery procedures from November 2016 through November 2021 were retrospectively interrogated for AH. These results were merged with postoperative patient outcomes data and analyzed for morbidity and mortality. Results. A single AH occurred in 1,087/5,937 (18.3%) procedures, and two or more AHs occurred in 224 (3.8%) procedures. Baseline characteristics show that AH is more frequently associated with higher complexity patients and operations. The primary outcome of operative mortality occurred in 113 (2.4%), 54 (5.0%), and 7 (3.1%) patients in the no AH, single AH, and multiple AH cohorts. After multivariable adjustment, the odds ratio for mortality was 1.15 (95% CI 0.79–1.67 and P = 0.46) for a single AH and 0.83 (95% CI 0.36–1.90 and P = 0.66) for multiple AH. There were no significant differences in readmission, length of stay, or a composite complication outcome between the cohorts after adjustment. Conclusions. In a large single-center experience, intraoperative anesthesia handoffs were not associated with adverse outcomes after cardiac surgery.

Background. Bioprosthetic mitral valves (MV) have limited durability. Dysfunction and degeneration of these valves can lead to reoperation and progressive heart failure. We investigated the frequency and predictors of MV bioprosthesis early degeneration within three years following MV replacement surgery. Methods. In this retrospective cohort study, we retrieved the data of consecutive patients who underwent bioprosthetic MV replacement through midsternotomy at Tehran Heart Center between 2013 and 2019. Based on the reviewed parameters of the bioprosthetic MV in the follow-up echocardiography, the patients were divided into two groups to compare the variables respecting early degeneration. Finally, the predictors of early degeneration were recognized using the Cox regression hazards model. Results. We reviewed and analyzed data of 177 patients from our hospital database. The mean age of the patients was 63.9 ± 11.7 years and 100 (56.5%) were women. 39 (22.0%) patients had experienced early degeneration and two (1.1% of the total) had died during the follow-up period. Patients in the degeneration group tended to have a history of stroke and renal failure, although not statistically significant. The sole independent predictor of early degeneration of bioprosthetic MV was a high MV mean gradient in the first postoperative echocardiography study (HR = 11.01, 95% CI: 4.80–25.24; P < 0.001). Conclusion. About 22.0% of our patients had echocardiographic criteria for early degeneration, and according to our results, increased MV gradients (without considering the reason) in the first postoperative echocardiography were the sole independent predictor for it. Careful valve selection can be essential in reducing early degeneration.

Background and Aim of the Study. To investigate if mitral valve (MV) surgery quality differs by hospital volume in New Jersey (NJ). Methods. Using the NJ State Inpatient Database, patients ≥18 years undergoing MV repair or replacement from 2016–2019 were identified. Centers were considered high-volume if they performed more than 50 mitral operations annually. Baseline characteristics and outcomes (in-hospital mortality, seven-day readmission, hospital length of stay (LOS), and postoperative complications) were evaluated for the population and by center volume. Subanalysis by center volume within each procedure was conducted. Results. Among 2,560 mitral operations, MV replacement (92.3% (n = 2,362)) was performed more often than repair. High- (4) and low-volume (15) centers performed 1,180 (46.1%) and 1,380 (53.9%) mitral surgeries, respectively. Charlson Comorbidity Indices did not differ by center volume, including in subgroup analyses. Low-volume centers had higher rates of Hispanic patients, low-income patients, and readmission rates. High-volume centers had more transfers, urgent/emergent admissions, higher rates of in-hospital mortality, and longer LOS. Postoperative complications did not differ by volume. The MV replacement cohort reflected many of the differences seen in the total population, in addition to seeing higher rates of heart failure at high-volume centers and stroke at low-volume centers. Within MV repairs, significantly more Hispanic patients presented to low-volume centers and high-volume centers had longer LOS. Multivariable analysis indicated that hospital volume was not correlated to in-hospital mortality for the total population and within each procedure. Conclusions. MV replacement is performed more frequently than repair. Hospital volume is not correlated with MV surgical quality, and more representative quality measures are needed.

Introduction. Tricuspid valve (TV) disease is substantially less common than mitral or aortic valve disease, and it is commonly missed due to the tolerability of stenosis or regurgitation. Adults seldom have primary tricuspid valve regurgitation, which is linked to rheumatic heart disease, infectious endocarditis, myxomatous valve disease, congenital heart disease, carcinoid syndrome, and/or infiltrative valvopathy. Materials and Methods. The authors examined the Valve Surgery Data Bank retrospectively to identify all patients who underwent TV replacement without concomitant surgeries between 2004 and 2014. In addition, the exclusion criteria suggested that all instances involving solitary valve repair were eliminated. Through visits or phone interviews, long-term follow-up was collected through the end of June 2022 in order to gather information on postoperative occurrences among the patients. The average follow-up time was 10.7 + 2.1 (5–15) years. Results. The overall survival rate was 90.9%. Survival rate was not significantly different between bioprostheses and mechanical ones (log rank p = 0.05). The incidence of endocarditis and valvar thrombosis in short-term was higher in the mechanical group than in the biological group, but the frequency of valve malfunction and redo surgery was higher in the replacement group. We found a higher incidence of valvular thrombosis, GI bleeding, and myocardial infarction rate in mechanical valve complications compared to the bioprosthetic group regarding late complications.

Background and Aim of the Study. The effects of sex on the prognosis of patients with acute type A aortic dissection (ATAAD) have still remained controversial. This study aimed to explore the sex differences in outcomes of ATAAD patients undergoing surgery. Methods. Data of patients with ATAAD who were operated in our center from 2010 to 2018 were retrospectively collected. Data on pre-, intra-, and postoperative courses were analyzed. Propensity score weighting was performed to balance the baseline characteristics. Multivariable logistic regression was used to assess predictors of early mortality in overall female and male patients. Results. A total of 1448 patients were enrolled, including 352 (24.3%) female patients and 1096 (75.7%) male patients. Females were significantly older than males (56.0 vs. 47.8 years, P < 0.001). Dissection was less extensive (Fuwai Ct: 85.8% vs. 91.3%, P = 0.003) and malperfusion syndrome was less frequently diagnosed (Penn Ab: 19.3% vs. 29.7%, P < 0.001) in females. Males experienced more aortic root replacement (Bentall: 14.2% vs. 24.9%, P < 0.001) and total arch replacement combined with frozen elephant trunk (56.8% vs. 75.8%, P < 0.001) with the prolonged operation time (6.1 vs. 6.4 hours, P = 0.001). In contrast, early mortality was higher in females (9.4% vs. 6.1%, P = 0.036). No differences were found in long-term survival and reoperation rates. After propensity score weighting, sex suggested no influence on both early and long-term outcomes. Cardiopulmonary bypass time was an independent risk factor for early mortality in both overall and sex-related populations according to the multivariable logistic regression. Conclusions. In ATAAD, different presentations and surgical strategies were noted in male and female patients. However, there were no significant differences in early and long-term outcomes between sexes after propensity score weighting.