Cardiopulmonary Bypass Duration Is an Independent Predictor of Morbidity and Mortality After Cardiac Surgery

Study protocol for an internahaational prospective non-randomised trial evaluating the long-term outcomes of transcatheter aortic valve implantation versus surgical aortic valve replacement for aortic-valve stenosis in patients at risk to severe valve obstruction: the TAVISAR trial

BACKGROUND

Aortic valve stenosis (AVS) represents the most prevalent primary valvular lesion necessitating surgical intervention or transcatheter intervention in Europe and North America. Its prevalence is increasing at a rapid rate as a consequence of the ageing population. A variety of mechanical interventions are available to determine the management of AVS; however, there is currently a paucity of robust data with which to perform a comparative analysis of the efficacy of surgical aortic valve replacement (SAVR) and that of conventional stented xenograft bioprostheses (BP) or sutureless aortic valves (SAV) and transcatheter aortic valve implantation (TAVI). The present study aims to compare the effectiveness and clinical outcomes of SAVR using BP or SAV technique and TAVI in patients with severe AVS.

METHODS AND ANALYSIS

A collaboration between three cardiac surgery centres across two European countries has resulted in the conception of the Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement trial. This prospective non-randomised trial is designed to evaluate the long-term outcomes of TAVI in comparison to SAVR for AVS in patients at risk of severe valve obstruction. The registry will enrol successive patients who have undergone mechanical intervention for AVS between January 2015 and December 2025. Investigators will assess the difference between replacement procedures for both the standard surgical approach and the transcatheter procedure. The principal clinical outcome under consideration will be the composite degree of all-cause mortality, ischaemic stroke or rehospitalisation at 10 years. The present study will also have a number of secondary endpoints, including all-cause mortality, followed by functional status, hospitalisation, neurocognition, physiological measures (echocardiographic assessment), adverse events and reoperation.

ETHICS AND DISSEMINATION

It is hypothesised that the nature of the trials will serve to minimise bias related to institutional volume and surgical experience. Each participating centre is required to have an aortic valve programme that enables proper follow-up and management of any late aortic events following replacement surgery for the AVS. The data collected will provide valuable insight into the comparative effectiveness of various surgical approaches, both standardised and advanced, in aortic valve surgery and TAVI. This comprehensive analysis will contribute significantly to the development of robust international guidelines.

TRIAL REGISTRATION NUMBER

Clinical Trial Gov.Com. ID: NCT05261204 IRB. ID: 2022011057.

Sutureless aortic valve and post-operative atrial fibrillation: Five-year outcomes from a propensity matched cohort study

BACKGROUND

The Perceval Sorin S (perceval valve) is a sutureless bioprosthetic designed for use in a high-risk cohort who may not be suitable for transcatheter aortic valve implantation or a conventional surgical aortic valve replacement (AVR).

AIM

To compare five-year post-operative outcomes in a cohort undergoing isolated AVR with the perceval valve to a contemporary cohort undergoing surgical AVR with a sutured bioprosthesis.

METHODS

This study was a retrospective, cohort study at a single tertiary unit. Between 2017 and 2023, 982 suitable patients were identified. 174 Perceval valve replacements were matched to 174 sutured valve replacements. Cohort characteristics, intra-operative details, and post-operative outcomes were compared between the two groups.

RESULTS

Time under the aortic cross-clamp (P < 0.001), time on the cardiopulmonary bypass (P < 0.001) and total operative time (P < 0.001) were significantly reduced in the Perceval group. Patients in the Perceval valve group were at a lower risk of postoperative pneumonia [odds ratio (OR) = 0.53 (0.29-0.94)] and atrial fibrillation [OR = 0.58 (0.36-0.93)]. After propensity-matching, all-cause mortality did not significantly differ between the two groups in the five-year follow-up period. Larger valve sizes conferred an increased risk of mortality (P = 0.020).

CONCLUSION

Sutureless surgical AVR (SAVR) is a safe and efficient alternative to SAVR with a sutured bioprosthesis, and may confer a reduced risk of post-operative atrial fibrillation. Clinician tendency towards 'oversizing' sutureless aortic valves translates into adverse clinical outcomes. Less time on the cardiopulmonary bypass circuit allows for the treatment of otherwise high-risk patients.

Early Outcomes in Severely Obese Patients Undergoing Sternum-Sparing Minimally Invasive Multivessel Artery Bypass Grafting Using Total Coronary Revascularization via Left Anterior Mini-Thoracotomy

Background/Objectives: Severe obesity significantly increases the risk of complications following full sternotomy in coronary artery bypass grafting (CABG). However, these patients are frequently excluded from less invasive, sternum-sparing surgical alternatives. This study aimed to assess the safety and practicality of a newly developed technique-Total Coronary Revascularization via left Anterior miniThoracotomy (TCRAT)-that avoids sternotomy in patients with severe obesity requiring multivessel CABG. Methods: From November 2019 to May 2024, a total of 502 non-emergency patients with multivessel coronary artery disease underwent CABG through a left anterior minithoracotomy using cardiopulmonary bypass (CPB) and cardioplegic arrest. Of these, 43 patients with a body mass index (BMI) exceeding 35.0 kg/m2 were classified as severely obese and included for subgroup analysis. Their outcomes were compared to those of the remaining 459 patients with BMI below 35.0 kg/m2. Key intraoperative variables-such as total operative time, CPB duration, aortic cross-clamp time, and graft strategy-were evaluated. Postoperative outcomes, such as the incidence of major adverse cardiac and cerebrovascular events, minor complications, and length of stay in ICU and hospital, were also analyzed. Results: Severely obese patients exhibited a longer total operation time (353.5 ± 83.6 min vs. 320.4 ± 73.4 min, p < 0.05). In contrast, no statistical differences were observed in aortic cross-clamp time (97.9 ± 27.6 min vs. 95.6 ± 33.0 min; p = 0.307) or CPB time (163.3 ± 35.0 min vs. 155.0 ± 42.9 min; p = 0.078). Both groups received a similar number of distal anastomoses (3.1 ± 0.7 vs. 3.0 ± 0.8; p = 0.194), and the frequency of total arterial revascularization was comparable (34.9% vs. 40.0%; p = 0.268). There were no differences between the groups in major complications, including hospital mortality (2.3% vs. 1.1%, p = 0.227), stroke (0.0% vs. 0.6% p = 0.300), or need for re-revascularization (0.0% vs. 1.1%, p = 0.248). Similarly, minor complications, such as wound healing issues (2.3% vs. 1.1%, p = 0.233) and revisions for bleeding (4.6% vs. 7.2%, p = 0.276), were comparable between groups. ICU stay (2.7 ± 4.5 days vs. 2.2 ± 4.0 days; p = 0.225) and total hospital stay (12.3 ± 9.6 days vs. 10.8 ± 8.6 days; p = 0.142) showed no meaningful differences. Conclusions: TCRAT can be performed safely and effectively in severely obese patients, providing a feasible minimally invasive option for complete coronary revascularization in cases of multivessel disease. This approach eliminates the complications associated with sternotomy, making it a valuable surgical alternative for this high-risk patient group.

Learning curve of the Ross procedure after more than 650 interventions: a single-centre, retrospective analysis†

OBJECTIVES

The Ross procedure has been associated with better long-term outcomes in selected patients. Nevertheless, its complexity has limited its adoption. The aim of this study was to assess the learning curve of the Ross procedure and to evaluate the impact of new surgeons joining an experienced Ross program.

METHODS

From 2011 to 2023, 673 consecutive Ross procedures were performed in adults (<69 years) at the Montreal Heart Institute. The cohort was divided into 3 groups depending on the previous experience of the operating surgeon. Safety (including mortality and major complications), efficiency (cardiopulmonary bypass and aortic cross-clamp times) and efficacy end-points (aortic regurgitation >1/4) were compared. Cumulative sum analyses were performed to evaluate mortality and major complications.

RESULTS

There were 3 (0.45%) peri-operative mortalities. All analysed outcomes exhibited temporal trends towards improvement. Major complications decreased from 9.5% in the Early period to 1.8% in the Late (P = 0.019). Similarly, there was a statistically significant improvement in median cardiopulmonary bypass (from 203.5 min in the Early period to 163.5 in the Late, P < 0.001) and aortic cross-clamp times (from 180 min in the Early period to 148 in the Late, P < 0.001).

CONCLUSIONS

Improvement in safety, efficiency and resource utilization were observed after an initial learning period. Addition of new surgeons to an established Ross program did not negatively impact surgical outcomes. Mortality and morbidity remained low and were compared favourably with predicted risks for conventional AVR. The Ross procedure is reproducible with adequate mentorship and support to help minimize individual learning curves.

CLINICAL TRIAL REGISTRATION NUMBER

#2017-1974.

Development and validation of a clinical prediction model for dialysis-requiring acute kidney injury following heart transplantation: a single-center study from China

OBJECTIVES

This study seeks to construct and internally validate a clinical prediction model for predicting new-onset dialysis-requiring acute kidney injury (AKI) following heart transplantation (HT).

METHODS

The Kaplan-Meier survival analysis and log-rank test were utilized for conducting the survival analysis. A clinical prediction model was developed to predict postoperative dialysis-requiring AKI, based on a logistic regression model and likelihood ratio test with Akaike Information Criterion. The performance of the prediction model was assessed using C-index, receiver operating characteristic curves, calibration curves, Brier score, and the Spiegelhalter Z-test. Clinical utility was evaluated using decision curve analysis and clinical impact curves.

RESULTS

This study included a total of 525 patients who underwent orthotopic HT in the single center located in Wuhan, China between January 2015 and December 2021, with 16.57% developing postoperative dialysis-requiring AKI. Patients who experienced postoperative dialysis-requiring AKI exhibited a lower overall survival rate. All enrolled participants were randomly allocated into derivation (n = 350) and validation (n = 175) cohorts at a ratio of 2:1. The final prediction model comprised six indicators: diabetes, stroke, gout, prognostic nutritional index, estimated glomerular filtration rate, and cardiopulmonary bypass duration. The prediction model demonstrated outstanding discrimination (C-index of 0.792 in the derivation cohort and 0.834 in the validation cohort) as well as calibration performance, indicating strong concordance between observed and nomogram-predicted probabilities. Subgroup analysis based on age, preoperative serum creatine levels, and year of surgery also exhibited robust discrimination and calibration capabilities.

CONCLUSIONS

Dialysis-requiring AKI following HT is associated with poor clinical prognosis. The prediction model, comprising six indicators, is capable of predicting dialysis-requiring AKI following HT. This prediction model holds promise in assisting both patients and clinicians in forecasting postoperative renal failure, thereby improving clinical management.

CLINICAL TRIAL NUMBER

Not applicable.

Development and Validation of Machine Learning Models for Adverse Events after Cardiac Surgery

Importance

Early recognition of adverse events after cardiac surgery is vital for treatment. However, the widely used Society of Thoracic Surgery (STS) risk model has modest performance in predicting adverse events and only applies <80% of cardiac surgeries.

Objective

To develop and validate machine learning (ML) models for predicting outcomes after cardiac surgery.

Design setting and participants

ML models, referred as Roux-MMC model, were developed and validated using a retrospective cohort extracted from the STS Adult Cardiac Surgery Database (ACSD) at Maine Medical Center (MMC) between January 2012 to December 2021. It was further validated on a prospective cohort of MMC between January 2022 to February 2024. The performance of Roux-MMC model is compared with the STS model.Exposure cardiac surgery.

Main outcomes and measures

Postoperative outcomes: mortality, stroke, renal failure, reoperation, prolonged ventilation, major morbidity or mortality, prolonged length of stay (PLOS) and short length of stay (SLOS). Primary measure: area under the receiver-operating curve (AUROC).

Results

A retrospective cohort of 9,841 patients (median [IQR] age, 67 [59-74] years; 7,127 [72%] males) and a prospective cohort of 2,305 patients (median [IQR] age, 67 [59-73] years; 1,707 [74%] males) were included. In the prospective cohort, the Roux-MMC model achieves performance for prolonged ventilation (AUROC 0.911 [95% CI, 0.887-0.935]), PLOS (AUROC 0.875 [95% CI, 0.848-0.898]), renal failure (AUROC 0.878 [95% CI, 0.829-0.921]), mortality (AUROC 0.882 [95% CI, 0.837-0.920]), reoperation (AUROC 0.824 [95% CI, 0.787-0.860]), SLOS (AUROC 0.818 [95% CI, 0.801-0.835]) and major morbidity or mortality (AUROC 0.859 [95% CI, 0.832-0.884]). The Roux-MMC model outperforms the STS model for all 8 outcomes, achieving 0.020-0.167 greater AUROC. The Roux-MMC model covers all cardiac surgery patients, while the STS model applies to only 65% in the retrospective and 77% in the prospective cohorts.

Conclusion and relevance

We developed ML models to predict 8 postoperative outcomes on all cardiac surgery patients using preoperative and intraoperative variables. The Roux-MMC model outperforms the STS model in the prospective cohort. The Roux-MMC model is built on STS ACSD, a data system used in ~1000 US hospitals, thus, it has the potential to easily applied in other hospitals.

Impact of preoperative frailty on new disability or death after cardiac surgery in elderly patients: a prospective cohort study

Background

Disability may be a potential adverse outcome of exposure to stressors in frail patients, and assessment of frailty may provide additional information for preoperative decision-making, but there is a lack of research on the impact of preoperative frailty on death or new disability after cardiac surgery. The main objective of this study was to evaluate the effect of preoperative frailty on short-term death or new disability after cardiac surgery in elderly individuals.

Patients and methods

This prospective cohort study included 351 patients aged ≥60 years who were scheduled to undergo elective open heart surgery at the Affiliated Hospital of Xuzhou Medical University from March 2023 to March 2024. Patients were examined prospectively using the Comprehensive Assessment of Frailty (CAF) score, which separated patients into frail and non-frail groups. The primary outcome was 90-day disability or death. Multivariate logistic regression models were used to estimate the association between frailty and 90-day new disability or death.

Results

An assessment of frailty was performed on 351 patients, and 325 patients were included in the final analysis. The prevalence of frailty was found to be 23.08%. New disability or death occurred within 90 days after surgery in 41 (12.6%) of our patients. In multivariate analysis, frailty [OR, 3.31; 95% CI, 1.43-7.62] was independently associated with 90-day new disability or death. Empirical ROC analysis showed that CAF (AUC = 0.762) predicted 90-day new disability or death postoperatively more reliably than the traditional risk assessment tools ASA + age (AUC = 0.656) and EuroSCORE II (AUC = 0.643).

Conclusion

The study demonstrates that preoperative frailty, bypass time, diabetes, BMI and EuroSCORE II are independent risk factors for 90-day new disability or death after cardiac surgery in elderly patients. Notably, frailty was a more effective predictor of 90-day new disability or death than the traditional risk predictors EuroSCORE II and ASA + age.

Outcomes of RDAVR with Coronary Revascularization: 3-year Results from the German INCA Registry

BACKGROUND

 The long-term outcomes of combined rapid-deployment aortic valve replacement (RDAVR) with coronary artery bypass graft surgery (CABG) are not well explored. We report 3-year results from the INCA registry on combined RDAVR with CABG.

METHODS

 INCA is a prospective, multicenter registry that enrolled 224 patients undergoing RDAVR with CABG at 10 cardiac institutions in Germany. Prosthetic valve hemodynamics, clinical outcomes, and quality of life (QoL) up to 3 years were assessed.

RESULTS

 The mean age of patients was 73.6 ± 6.1 years, and the mean logistic EuroSCORE was 7.8 ± 6.0%. The mean number of distal arterial and venous anastomoses was 3.13 ± 1.56, aortic cross-clamp time was 79.4 ± 24.1 minutes, cardiopulmonary bypass time was 109.6 ± 34.5 minutes, and operation time was 224.2 ± 62.7 minutes. The majority of implanted valve size was 25 mm. At baseline, 11 patients (4.9.%) had a permanent pacemaker. Postoperatively, 17 patients (7.6%) required a new pacemaker implantation (5.4% valve-related). All-cause mortality at 30 days was 2.2%, and 11.2% at 3 years. Patient QoL (SF-12v2) was significantly restored and maintained for up to 3 years (p < 0.001). Five patients (0.9%) underwent reoperation related to endocarditis. The postimplant mean gradient was 9.2 ± 3.7 at discharge and 8.9 ± 4.6 mm Hg at 3 years.

CONCLUSION

 Combined RDAVR with CABG procedure is safe and effective over time. It offers stable and low transvalvular gradients with satisfactory clinical outcomes at 3 years. The pacemaker rate appears to be slightly increased, with no significant clinical effect at 3 years.

Association between cardiopulmonary bypass duration and early major adverse cardiovascular events after surgical repair of supravalvular aortic stenosis

Background

Patients who underwent surgical repair of supravalvular aortic stenosis (SVAS) are at high risk for postoperative major adverse cardiovascular events (MACE). This study aimed to investigate the association between cardiopulmonary bypass (CPB) duration and MACE occurring during postoperative hospitalization or within 30 days post-surgery.

Methods

Patients who underwent surgical repair of SVAS from 2002 to 2019 at Beijing Fuwai Hospital and Yunnan Fuwai Hospital were included in this study. Patients were stratified into "CPB duration >2 h" and "CPB duration ≤2 h" groups based on intraoperative CPB duration. Various statistical methodologies were employed to investigate the association between CPB duration and early postoperative MACE, including multivariate adjustment, propensity score adjustment, propensity score matching, and logistic regression based on propensity score weighting.

Results

297 participants were included and 164 were finally matched. In the propensity score-matched cohort, CPB duration was positively associated with early postoperative MACE (odds ratio = 18.13; 95% confidence interval 2.33-140.86; P = 0.006). Consistent results were obtained in the Inverse probability of treatment-weighted, standardized mortality ratio-weighted, pairwise algorithmic-weighted, and overlap-weighted models.

Conclusion

Patients with CPB duration >2 h were at a higher risk of early postoperative MACE compared to those with CPB duration ≤2 h. This emphasized the significance of minimizing CPB exposure for the prognosis of patients with SVAS.

Combined Mitral and Aortic Valve Surgery Through a Right Minithoracotomy: A Single-Center Experience

OBJECTIVE

Minimally invasive combined mitral and aortic valve surgery is still uncommon. We report our experience performing multiple valve procedures through a right-sided minithoracotomy.

METHODS

We present an observational case series with a retrospective analysis of 38 patients who underwent double valve surgery through right anterior thoracotomy from November 2013 to November 2023.

RESULTS

The median age of our population was 72 years, and 61% were female patients. The median EuroSCORE II was 2.27. Three patients (7.9%) had redo operations. The median cardiopulmonary bypass (CPB) and cross-clamp times were 98 and 85 min, respectively. No conversion to full sternotomy was necessary. In-hospital mortality was 2.6% (1 patient); the patient died of septic shock and consequent multiorgan failure. Of the patients, 53% required transfusions with packed blood cells. Postoperative atrial fibrillation was observed in 12 patients (32%), and 2 patients (5.2%) required pacemaker implantation due to third-degree atrioventricular block. Also, 1 stroke (2.6%) and 1 rethoracotomy for bleeding were observed. The median ventilation time was 10 h. The median intensive care unit and postoperative length of stay were 2 days and 7.5 days, respectively. Survival at 1, 3, 5, and 10 years was 93.8%, 86.3%, 86.3%, and 77.2%, respectively, with a median follow-up time of 6.5 years. Freedom from reintervention at 1, 3, 5, and 10 years was 96.8%, 89.5%, 85.0%, and 69.5%, respectively, with a median follow-up time of 5.7 years.

CONCLUSIONS

In our experience, a minimally invasive approach for combined aortic and mitral valve surgery is safe and feasible, with acceptable CPB and cross-clamp times and good outcomes. Therefore, it can be an attractive option for patients with double valve diseases.

Ultrafiltration During Cardiac Surgery Requiring Cardiopulmonary Bypass and Its Effect on Acute Kidney Injury

OBJECTIVE

To explore whether ultrafiltration (UF) volume adjusted for weight is associated with an increased risk of acute kidney injury (AKI) after cardiopulmonary bypass (CPB) in cardiac surgery patients.

DESIGN

A retrospective cohort study.

SETTING

Single-center study at a tertiary academic medical center.

PARTICIPANTS

A total of 2369 adult patients (age ≥18 years) who underwent cardiac surgery with CPB between January 2018 and August 2019.

INTERVENTION

The cohort was divided into 4 groups based on weight-adjusted conventional UF volume: 0 (no UF), 0.1 to 17.9 mL, 18 to 29.9 mL, and >30 mL ultrafiltration for each kg of body weight. Demographic data, laboratory findings, comorbidities, medications, and surgical details were collected. Postoperative AKI was defined by the KDIGO (Kidney Disease: Improving Global Outcomes) staging criteria and assessed in all UF groups. The association between UF volume and AKI according to nadir hemoglobin (Hb) level and red blood cell transfusion volume was explored.

RESULTS

Postoperative AKI occurred in 840 patients (35.4%). The incidence of AKI post-CPB in patients was similar in patients with 0 mL/kg (34.4%; n = 123), 0.1 to 17.9 mL/kg (34.3%; n = 387), and 18 to 29.9 mL/kg (33.7%; n = 173) of UF volume. The patients with UF volume >30 mL/kg had a higher incidence of AKI (42.7%; n = 157; p = 0.019). For each additional 10 mL/kg increase in UF, the odds ratio (OR) of AKI was 1.14 (95% confidence interval [CI], 1.07-1.20; p < 0.001) following adjustments for preoperative covariates. However, the association was mitigated following adjustments for preoperative and intraoperative covariates (OR, 1.07; 95% CI, 0.99-1.16; p = 0.076). Although higher UF also was associated with an increased risk of AKI in patients with nadir Hb levels of 6 to 8 g/dL (adjusted OR, 1.24 and 1.22; p = 0.02), it was not significantly associated with AKI when nadir Hb was 10 to 12 g/dL. Red blood cell transfusion volume was not related to changes in AKI incidence.

CONCLUSIONS

This study suggests that conventional UF is a potential risk factor for AKI incidence following surgery with CPB. The results demonstrate an association between higher weight-adjusted ultrafiltration volume and a higher incidence of AKI. Future studies should incorporate a multicenter, prospective approach to test the generalizability of the present findings and validate modified ultrafiltration strategies that use hemodynamic variables to determine fluid removal volume.

Enhancing mortality prediction after coronary artery bypass graft: a machine learning approach utilizing EuroScore

Aim: We developed a machine learning model using EuroScore assumptions and preoperative and intraoperative risk factors to predict mortality after coronary artery bypass graft (CABG). Materials & methods: We retrospectively examined data from 108 CABG patients at King Abdullah University Hospital, classifying them into risk groups via EuroScore and predicting mortality through random forest classification. Results: High-risk patients displayed longer surgical times and significant factors such as age and surgery choice. The median EuroScore was 0.95 (0.5-6.4). The model yielded high AUC scores (0.98, 0.95) indicating strong predictive accuracy. Conclusion: Our findings showed that the machine learning models combined with the EuroScore significantly improve post-CABG mortality prediction. For further validation, larger datasets are needed.

Prolonged Cardiopulmonary Bypass Time-Induced Endothelial Dysfunction via Glypican-1 Shedding, Inflammation, and Matrix Metalloproteinase 9 in Patients Undergoing Cardiac Surgery

OBJECTIVES

A prolonged cardiopulmonary bypass (CPB) time of over 180 min is linked to poorer outcomes and higher mortality in cardiac surgery. This study examines how glypican-1 shedding, matrix metallopeptidase 9 (MMP9), and the pro-inflammatory cytokine IL-1β may contribute to endothelial dysfunction in patients undergoing on-pump surgery with an extended CPB.

METHODS

Fifty-one patients undergoing cardiac surgical procedures were divided into two groups based on the intraoperative CPB duration: (i) normal CPB (<180 min, n = 23) and (ii) prolonged CPB (>180 min, n = 28). The preoperative, intraoperative, and postoperative plasma levels of glypican-1, MMP9, and IL-1β were measured.

RESULTS

Before surgery, the plasma levels of glypican-1, MMP9, and IL-1β were comparable between the normal CPB and the prolonged CPB groups. However, after the end of the CPB, all three markers showed significant elevation in the prolonged CPB group compared to the normal CPB group. Significant correlations were observed between the intraoperative and postoperative levels of MMP9, IL-1β, and glypican-1. A strong positive correlation was also observed between the intraoperative and postoperative levels of glypican-1 and the duration of the CPB.

CONCLUSIONS

A prolonged CPB triggers a systemic inflammatory response and activates MMP9, leading to glypican-1 shedding and endothelial dysfunction.

In operating room extubation after cardiac surgery is associated with decreased incidence of in hospital new postoperative atrial fibrillation

OBJECTIVES

This study aims to characterize the risks and benefits of in-OR extubation after cardiac surgery.

DESIGN

This is a retrospective chart review.

SETTING

Single tertiary care hospital.

PARTICIPANTS

Cardiac surgical patients >18 years. Exclusion criteria included patients extubated after 6 h in the ICU, those with a history of congenital heart disease (CHD), those intubated prior to arrival to the OR, procedures including circulatory arrest and/or selective cerebral perfusion, cardiothoracic transplantation, and intraoperative death. De-identified data was collected via the hospital's electronic medical record.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Perioperative data was collected for 726 patients, of which 303 (42 %) were extubated in the OR. Multivariable regression models were derived with covariates based on expert clinical reasoning. When compared to fast track extubation, in-OR extubation was independently associated with decreased index hospitalization length of stay (-1.74, 95 % CI [-2.22, -1.08], p < 0.001) and decreased incidence of in-hospital new post-operative atrial fibrillation (OR 0.56 95 % CI [0.37, 0.86], p < 0.01). There were no differences in persistent vasoactive therapy requirement, postoperative mechanical circulatory support or extubation failure.

CONCLUSIONS

In-OR extubation is associated with decreased index hospitalization length of stay and decreased new onset in-hospital atrial fibrillation.

Is extended resection for locally advanced thoracic cancer with cardiopulmonary bypass justified?

BACKGROUND

Resection of intrathoracic tumor with cardiopulmonary bypass (CPB) remains a relatively under-reported intervention in literature, and its role in managing locally advanced mediastinal and lung cancers is a topic of ongoing debate. Our aim was to review our experience and assess the role of CPB for treating locally advanced mediastinal and lung cancers.

METHODS

Between 2015 and 2020, this study initially included 10 patients with primary locally advanced thoracic malignancies with apparent adjacent cardiovascular invasion demonstrated by thoracic imaging scans. Operation was performed based on a multidisciplinary tumor board consensus. Eventually, 8 patients (3 primary lung cancers and 5 mediastinal cancers) received either salvage or elective resection with CPB; two completed surgery without requiring CPB.

RESULTS

Regarding the extent of adjacent structure involvement, 4 patients presented with involvement of the superior vena cava (SVC), 1 involved the right atrium (RA), 2 involved the SVC and RA, and 1 involved the SVC, the origin of main pulmonary artery, and the ascending aorta. Thirty-day mortality occurred in two of three patients receiving salvage surgery due to respiratory insufficiency. With the long-term follow-up, one patient died of recurrence 25 months postoperatively, one survived with recurrence 30 months postoperatively, and four were alive without recurrence for 35, 36, 49, and 107 months after operations.

CONCLUSION

In certain patients, particularly for elective surgical candidates rather than salvage resection, CPB allows for extended resection of locally advanced thoracic cancers with acceptable perioperative safety and survival.

Right anterior thoracotomy vs. upper hemisternotomy for aortic valve replacement with Perceval S: is there a difference?

Background

Our study aimed to evaluate the early outcomes of aortic valve replacement with Perceval S sutureless valve through the right anterior thoracotomy and upper hemisternotomy approaches, and to determine if there are any differences between these two approaches.

Methods

We carried out a study using data from 174 patients who underwent minimally invasive Perceval S valve implantation for aortic valve stenosis between January 2018 and August 2023. This was a retrospective, single-center observational study. The patients were divided into two groups: the hemisternotomy group (n = 100) and the right anterior thoracotomy group (n = 74).

Results

The overall in-hospital mortality was 1,7%. The cardiopulmonary bypass and cross-clamp times were longer in the right anterior thoracotomy group (p < .001). There were no statistically significant differences in terms of stroke, paravalvular leak, mechanical ventilation time, blood transfusion requirements, pacemaker implantation, reexploration for bleeding, conversion, wound infection, or in-hospital stay. Postoperative chest drainage was lower (p < .001) and postoperative atrial fibrillation occurred less frequently (p = .044) in the right anterior thoracotomy group. The median intensive care unit stay was shorter in the right anterior thoracotomy group (p = .018).

Conclusion

Aortic valve replacement with the Perceval S valve through either an upper hemisternotomy or a right anterior thoracotomy is a procedure associated with low perioperative complication rates. Right anterior thoracotomy for an aortic valve replacement with the Perceval S valve was associated with lower postoperative bleeding, a lower postoperative atrial fibrillation incidence and a shorter intensive care unit stay compared to upper hemistornotomy.

Predictive role of cardiopulmonary bypass exposure indexed to body surface area on postoperative organ dysfunction: a retrospective cohort study

OBJECTIVES

Long cardiopulmonary bypass times are associated with adverse postoperative outcomes and increased healthcare resource use. It is likely that this effect is pronounced in smaller patients. Previous studies have been criticized for not taking into consideration that prolonged bypass times are often due to higher complexity. The purpose of this study was to investigate the relationship between bypass index (bypass time/body surface area) and adverse postoperative events.

METHODS

Single-centre, retrospective cohort study including 2413 patients undergoing cardiac surgery on cardiopulmonary bypass from June 2018 to April 2020. Length of hospital stay, as surrogate marker of postoperative morbidity, was selected as primary outcome. The strength of association between bypass index and the primary outcome was assessed with linear regression analysis. Secondary outcomes included new onset renal, pulmonary or cardiac rhythm dysfunction. The predictive value of bypass index was assessed with linear regression analysis; univariate and multiple regression were used to assess the strength of association between Bi and the secondary outcomes.

RESULTS

Bypass index was predictive for length of stay at univariate (Relative Risk (RR): 1.004, P < 0.001) and at multivariable (RR: 1.003, P < 0.001) analysis. The association between bypass index and new renal (mean difference: 14.1 min/m2, P < 0.001) and cardiac rhythm dysfunction (mean difference: 12.6 min/m2) was significant. This was not true of postoperative lung dysfunction (mean difference: -1.5 min/m2, P = 0.293).

CONCLUSIONS

Bypass index, calculated as total bypass time/patient body surface area, is predictive of postoperative morbidity and resource utilization after cardiac surgery on pump.

Early postoperative outcomes of modified del Nido cardioplegia in coronary artery bypass surgery in patients with low ejection fraction

Background

This study aimed to investigate the intraoperative and early postoperative effects of modified del Nido cardioplegia (DNC) compared to classic blood cardioplegia (BC) in patients with impaired left ventricular ejection fraction (EF) who underwent isolated coronary artery bypass grafting (CABG).

Methods

A total of 123 patients (108 males, 15 females; mean age: 62.2±8.5 years; range, 42 to 78 years) with an EF of 35% or lower who underwent on-pump CABG were included in the retrospective study between December 2022 and December 2023. The patients were divided into two groups according to the type of cardioplegia used: Group 1 (n=74) was designated as the BC group, and Group 2 (n=49) was designated as the DNC group. The groups were compared in terms of aortic cross-clamp duration, cardiopulmonary bypass (CPB) duration, need for defibrillation during weaning from CPB, positive inotrope requirement, intra-aortic balloon pump requirement, postoperative troponin-I levels, postoperative atrial fibrillation occurence, postoperative prolonged ventilation, development of postoperative neurologic complications, need for reintervention due to postoperative bleeding, postoperative transfusion requirement, and EF values at one month after the operation.

Results

There was no significant difference between the two groups in the terms of aortic cross-clamp and CPB duration (p=0.955 vs. p=0.816). Additionally, there was no significant difference in the need for intra-aortic balloon pump usage between the two groups (p=0.105). Dopamine and dobutamine usage were significantly lower in Group 2 (p=0.04 and p=0.05, respectively). The intraoperative requirement for defibrillation was significantly lower in Group 2 (p=0.01). In addition, troponin levels at 12 h postoperatively were significantly lower in Group 2 (p=0.03). The incidence of postoperative atrial fibrillation was significantly lower in Group 2 (p=0.02). Moreover, there was no significant difference in EF values at one month after the operation (p=0.08).

Conclusion

In patients who underwent CABG with reduced EF, modified DNC provided myocardial protection comparable to classic BC. Additionally, the need for intraoperative defibrillation and postoperative inotropic agents, as well as the incidence of postoperative atrial fibrillation, were lower in patients operated with DNC.

Liver Status Assessment After Coronary Artery Bypass Grafting

Background Coronary artery bypass grafting (CABG) is a common surgical intervention used to treat severe coronary artery disease. The Model for End-Stage Liver Disease (MELD) score has become a widely used prognostic index for assessing the severity of liver disease and prioritizing liver transplantation. However, its utility in predicting outcomes in cardiac surgery procedures has not been extensively evaluated. Methods This retrospective study gathered data on patients who underwent CABG or CABG combined with other concomitant surgical interventions, such as carotid common or external carotid artery endarterectomy, thoracic aortic aneurysm repair, and aortic or mitral valve replacement or decalcification procedures, at a single tertiary care facility from January 2011 to December 2020. Researchers collected demographic, clinical, and laboratory information, including MELD score and European System for Cardiac Operative Risk Evaluation (EuroSCORE) data. The patients were divided into two groups: the first group included only those who underwent CABG, while the second group comprised patients who underwent CABG along with other concomitant cardiac interventions. Results The MELD score at discharge was significantly higher in the CABG and other interventions group compared to the CABG-only group (median = 14.09, IQR = 7.41-18.7 vs. median = 6.41, IQR = 4.61-9.44, p < 0.001). However, the difference in MELD score at admission between the two groups was not statistically significant (p = 0.328). A p-value < 0.05 was considered statistically relevant, indicating that liver function worsened postoperatively in the patients with additional interventions. The EuroSCORE was also significantly higher in the CABG and other interventions group, suggesting a higher surgical risk as expected (median = 5.74, IQR = 3.54-11.47 vs. median = 3.34, IQR = 1.97-5.66, p < 0.001). Additionally, differences in laboratory parameters, especially coagulation and hemostasis indicators throughout the postoperative period, including the ICU stay (divided into four equal periods based on each patient's total ICU length of stay) and at discharge, indicate a more complex biological state in patients with additional interventions. These findings may have implications for perioperative management and long-term outcomes. Conclusions The elevated MELD score in patients undergoing CABG with additional interventions emphasizes the need for close monitoring of liver function and coagulation status. Evaluating hepatic status preoperatively would be beneficial, and incorporating liver-protective strategies could help mitigate postoperative repercussions. It may also be useful to include liver function parameters in existing cardiovascular risk scores to improve risk assessment.

Sutureless Valves, a "Wireless" Option for Patients With Aortic Valve Disease: JACC State-of-the-Art Review

Transcatheter technologies triggered the recent revision of the guidelines that progressively widened the indications for the treatment of aortic stenosis. On the surgical realm, a technology avoiding the need for sutures to anchor the prosthesis to the aortic annulus has been developed with the aim to reduce the duration of cardiopulmonary bypass and simplify the process of valve implantation. In addition to a transcatheter aortic valve replacement (TAVR)-like stent that exerts a radial force, these so-called "rapid deployment valves" or "sutureless valves" for aortic valve replacement also have cuffs to improve sealing and reduce the risk of paravalvular leak. Despite promising, the actual advantage of sutureless valves over traditional surgical procedures (surgical aortic valve replacement) or TAVR is still debated. This review summarizes the current comparative evidence reporting outcomes of "sutureless valves" for aortic valve replacement to TAVR and surgical aortic valve replacement in the treatment of aortic valve stenosis.

Single-center real-world data and technical considerations from 100 consecutive patients treated with the Perceval aortic bioprosthesis

Objectives

Although the Perceval sutureless aortic valve bioprosthesis presents a feasible alternative to conventional aortic valve prostheses, the extent of its applicability with respect to technical considerations for a real-world patient collective is still under debate.

Methods

One hundred patients received the Perceval prosthesis [males: 59; age: 72.5 (7.3-79) years] between December 2015 and February 2023 [EuroSCORE II: 2.8 (1.7-5.4)] for an aortic valve replacement (AVR), with additional concomitant procedures, for underlying severe aortic valve stenosis [n = 93 (93)], endocarditis [n = 5 (5)], and redo AVR [n = 7 (7)] including a prior surgical AVR [n = 4 (4)] and a failed transcatheter aortic valve implantation [n = 3 (3)]. Surgery was conducted primarily by median sternotomy [n = 71 (71)] and, alternatively, by the upper hemisternotomy approach [n = 29 (29)].

Results

Over a median follow-up time of 36.5 (16.5-53) months, eight patients (8%) underwent postoperative pacemaker implantation, with five (5%) due to high-grade atrioventricular block, while nine patients experienced a stroke (9%). The median values of maximum and mean gradients across all valve sizes were 22 (18-27.5) mmHg and 10 (13-18) mmHg, respectively. Two patients (2%) had moderate and one (1%) had severe paravalvular leakage, with the latter presenting the only case of underlying valve migration and induced redo AVR with valve explantation 2 days following initial surgery. Thirty-day mortality (and overall mortality) was 5% and 26%, respectively.

Conclusion

The implantation of the Perceval bioprosthesis is feasible for a variety of indications, with excellent hemodynamic results and low complication rates in a real-world high-risk patient collective.

Vasoactive-Inotropic Score as a Promising Predictor of Acute Kidney Injury in Adult Patients Requiring Extracorporeal Membrane Oxygenation

Acute kidney injury (AKI) is a common complication in patients supported by extracorporeal membrane oxygenation (ECMO). Vasoactive-Inotropic Score (VIS) serves as an indicator of the extent of cardiovascular drug support provided. Our objective is to assess the relationship between the VIS and ECMO-associated AKI (EAKI). This single-center retrospective study extracted adult patients treated with ECMO between August 2016 and September 2022 from an intensive care unit (ICU) in a university hospital. A total of 126 patients requiring ECMO support were included in the study, of which 76% developed AKI. Multivariate logistic regression analysis identified VIS-max Day1 (odds ratio [OR]: 1.025, 95% confidence interval [CI]: 1.007-1.044, p = 0.006), VIS-max Day2 (OR: 1.038, 95% CI: 1.007-1.069, p = 0.015), VIS-mean Day1 (OR: 1.048, 95% CI: 1.013-1.084, p = 0.007), and VIS-mean Day2 (OR: 1.059, 95% CI: 1.014-1.107, p = 0.010) as independent risk factors for EAKI. VIS-max Day1 showing the best predictive effect (Area under the receiver operating characteristic curve (AUROC): 0.80, sensitivity: 71.87%, specificity: 80.00%) for EAKI with a cutoff value of 33.33. Surprisingly, VIS-mean Day2 was also excellent at predicting 7 day mortality (AUROC: 0.77, sensitivity: 87.50%, specificity: 56.38%) with a cutoff value of 8.67. In conclusion, VIS could independently predict EAKI and 7 day mortality in patients with ECMO implantation, which may help clinicians to recognize the poor prognosis in time for early intervention.

A review and meta-analysis of conventional sternotomy versus minimally invasive mitral valve surgery for degenerative mitral valve disease focused on the last decade of evidence

OBJECTIVES

Early meta-analyses comparing minimally invasive mitral valve surgery (MIMVS) with conventional sternotomy (CS) have determined the safety of MIMVS. We performed this review and meta-analysis based on studies from 2014 onwards to examine the differences in outcomes between MIMVS and CS. Specifically, some outcomes of interest included renal failure, new onset atrial fibrillation, mortality, stroke, reoperation for bleeding, blood transfusion and pulmonary infection.

METHODS

A systematic search was performed in six databases for studies comparing MIMVS with CS. Although the initial search identified 821 papers in total, nine studies were suitable for the final analysis. All studies included compared CS with MIMVS. The Mantel - Haenszel statistical method was chosen due the use of inverse variance and random effects. A meta-analysis was performed on the data.

RESULTS

MIMVS had significantly lower odds of renal failure (OR: 0.52; 95% CI 0.37 to 0.73, p < 0.001), new onset atrial fibrillation (OR: 0.78; 95% CI 0.67 to 0.90, p < 0.001), reduced prolonged intubation (OR: 0.50; 95% CI 0.29 to 0.87, p = 0.01) and reduced mortality (OR: 0.58; 95% CI 0.38 to 0.87, p < 0.01). MIMVS had shorter ICU stay (WMD: -0.42; 95% CI -0.59 to -0.24, p < 0.001) and shorter time to discharge (WMD: -2.79; 95% CI -3.86 to -1.71, p < 0.001).

CONCLUSION

In the modern era, MIMVS for degenerative disease is associated with improved short-term outcomes when compared to the CS.

Efficacy of a surgical cardiac ablation clamp using nanosecond pulsed electric fields: An acute porcine model

OBJECTIVE

To examine the effectiveness of a recently developed nonthermal technology, nanosecond pulse-field ablation (nsPFA), for surgical ablation of the atria in a beating heart porcine model.

METHODS

Six pigs underwent sternotomy and ablation using an nsPFA parallel clamp. The ablation electrodes (53 mm long) were embedded in the jaws of the clamp. Nine lesions per pig were created in locations chosen to be representative of the Cox-maze procedure. Four lesions were intended to electrically isolate parts of the atrium: the right atrial appendage, left atrial appendage, right pulmonary veins, and left pulmonary veins. For these lesions, exit block testing was performed both after ablation and before euthanasia; the time between the 2 tests was 3.3 ± 0.5 hours (range, 2-4 hours). Using purse string sutures, 5 more lesions were created up to the superior vena cava, down to the inferior vena cava, across the right atrial free wall, and at 2 distinct locations on the left atrial free wall. The clamp delivered a train of nanosecond duration pulses, with a total duration of 2.5 seconds, independent of tissue thickness. The heart tissue was stained with 1% triphenyltetrazolium chloride after a dwelling period of 2 hours. Subsequently, each lesion was cross sectioned at 5-mm intervals to assess the ablation depth and transmurality. In some sections, transmurality could not be established on the basis of triphenyltetrazolium chloride staining alone; for these lesions, Gomori-trichrome stains were used, and the histologic sections were evaluated for transmurality.

RESULTS

The ablation time was 2.5 seconds per lesion, for a total of only 22.5 seconds ablation time to create 9 lesions. A total of 53 lesions were created, resulting in 388 separate histologic sections. Transmurality was established in 386 sections (99.5%). Mean tissue thickness was 3.1 ± 1.5 mm (range, 0.2-8.6 mm). Exit block was confirmed in 23 of the 24 lesions (96%) postablation and 23 of 24 (96%) before the animals were humanely killed. Over the course of the procedure, neither pulse-induced arrhythmias nor any other complications were noted.

CONCLUSIONS

The novel nsPFA clamp device was effective in creating acute conduction block and transmural lesions in both the right and left atria in an acute porcine model. This nonthermal energy source has great potential to both shorten procedural time and enable effective ablation in the beating heart.

POBS-Card, a new score of severe bleeding after cardiac surgery: Construction and external validation

Objective

Bleeding after cardiac surgery leads to poor outcomes. The objective of the study was to build the PeriOperative Bleeding Score in Cardiac surgery (POBS-Card) to predict bleeding after cardiac surgery.

Methods

We conducted a retrospective cohort study in 2 academic hospitals (2016-2019). Inclusion criteria were adult patients after cardiac surgery under cardiopulmonary bypass. Exclusion criteria were heart transplantation, assistance, aortic dissection, and preoperative hemostasis diseases. Bleeding was defined by the universal definition for perioperative bleeding score ≥2. POBS-Card score was built using multivariate regression (derivation cohort, one center). The performance diagnosis was assessed using the area under the curve in a validation cohort (2 centers) and compared with other scores.

Results

In total, 1704 patients were included in the derivation cohort, 344 (20%) with bleeding. Preoperative factors were body mass index <25 kg/m2 (odds ratio [OR], 1.48 [1.14-1.93]), type of surgery (redo: OR, 1.76 [1.07-2.82]; combined: OR, 1.81 [1.19-2.74]; ascendant aorta: OR, 1.56 [1.02-2.38]), ongoing antiplatelet therapy (single: OR, 1.50 [1.09-2.05]; double: OR, 2.00 [1.15-3.37]), activated thromboplastin time ratio >1.2 (OR, 1.44 [1.03-1.99]), prothrombin ratio <60% (OR, 1.91 [1.21-2.97]), platelet count <150 g/L (OR, 1.74 [1.17-2.57]), and fibrinogen <3 g/L (OR, 1.33 [1.02-1.73]). In the validation cohort of 597 patients, the area under the curve was 0.645 [0.605-0.683] and was superior to other scores (WILL-BLEED, Papworth, TRUST, TRACK). A threshold >14 predicted bleeding with a sensitivity of 50% and a specificity of 73%.

Conclusions

POBS-Card score was superior to other scores in predicting severe bleeding after cardiac surgery. Performances remained modest, questioning the place of these scores in the perioperative strategy of bleeding-sparing.

Surgical Aortic Valve Replacement and Renal Dysfunction: From Acute Kidney Injury to Chronic Disease

Background: Surgical aortic valve replacement (SAVR) is often complicated by acute kidney injury (AKI). Identifying patients at risk of AKI is important to start nephroprotective strategies or renal replacement therapy (RRT). This study investigated the incidence and risk factors of post-operative AKI in SAVR patients. Chronic kidney disease (CKD) developed in the post-cardiac-surgery follow-up period was also assessed. Methods: A total of 462 SAVR patients were retrospectively enrolled. The primary endpoint was the occurrence rate of AKI after surgery. Kidney recovery, during two planned outpatient clinic nephrological visits within 12 months after the surgery, was assessed. Results: A total of 76 patients experienced an AKI event. A Kaplan-Meier analysis revealed that subjects with CKD stage IV had a time to progression of 2.7 days, compared to patients with stages I-II, who were characterized by the slowest progression time, >11.2 days. A Cox regression indicated that CKD stages predicted a higher risk of AKI independently of other variables. During their ICU stay, 23 patients died, representing 5% of the population, most of them requiring RRT during their ICU stay. A severe CKD before the surgery was closely related to perioperative mortality. During the follow-up period, 21 patients with AKI worsened their CKD stage. Conclusions: AKI represents a common complication for SAVR patients in the early post-operative period, prolonging their ICU stay, with negative effects on survival, especially if RRT was required. Pre-operative CKD >3 stage is an independent risk factor for AKI in patients undergoing SAVR.

Cardiopulmonary bypass parameters improve the prediction of 30-day mortality following cardiac surgery

Currently 30-day mortality is commonly used as a quality indicator for cardiac surgery; however, prediction models have not included the role of cardiopulmonary bypass (CPB). We hypothesized that reproducing currently utilised prediction model methods of 30-day mortality using the Australian and New Zealand Collaborative Perfusion Registry (ANZCPR) would identify relevant CPB predictors. Nine centers in Australia and New Zealand collected data using the ANZCPR between 2011-2020. CPB parameter selection was determined by evaluating association with 30-day mortality. Data were divided into model creation (n = 15,073) and validation sets (n = 15,072). Bootstrap sampling and automated variable selection methods were used to develop candidate models. The final model was selected using prediction mean square error and Bayesian Information Criteria. The average receiver operating characteristic (ROC), p-value for Hosmer-Lemeshow chi-squared test and MSE were obtained from multifold validation. In total, 30,145 patients were included, of which 735 (2.4%) died within 30 day of surgery. The area under the ROC curve for the model including CPB parameters was significantly greater than preoperative risk factors only (0.829 vs 0.783, p < 0.001). CPB parameters included in the predictive model were CPB time, red blood cell transfusion, mean arterial pressure <50 mmHg, minimum oxygen delivery, cardiac index <1.6 L/min/m2. CPB parameters improve the prediction of 30-day mortality. Randomised trials designed to evaluate modifiable CPB parameters will determine their impact on mortality.

Difference Between Cardiopulmonary Bypass Time and Aortic Cross-Clamping Time as a Predictor of Complications After Coronary Artery Bypass Grafting

INTRODUCTION

Along with cardiopulmonary bypass time, aortic cross-clamping time is directly related to the risk of complications after heart surgery. The influence of the time difference between cardiopulmonary bypass and cross-clamping times (TDC-C) remains poorly understood.

OBJECTIVE

To assess the impact of cardiopulmonary bypass time in relation to cross-clamping time on immediate results after coronary artery bypass grafting in the Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) II.

METHODS

Analysis of 3,090 patients included in REPLICCAR II database was performed. The Society of Thoracic Surgeons outcomes were evaluated (mortality, kidney failure, deep wound infection, reoperation, cerebrovascular accident, and prolonged ventilation time). A cutoff point was adopted, from which the increase of this difference would affect each outcome.

RESULTS

After a cutoff point determination, all patients were divided into Group 1 (cardiopulmonary bypass time < 140 min., TDC-C < 30 min.), Group 2 (cardiopulmonary bypass time < 140 min., TDC-C > 30 min.), Group 3 (cardiopulmonary bypass time > 140 min., TDC-C < 30 min.), and Group 4 (cardiopulmonary bypass time > 140 min., TDC-C > 30 min.). After univariate logistic regression, Group 2 showed significant association with reoperation (odds ratio: 1.64, 95% confidence interval: 1.01-2.66), stroke (odds ratio: 3.85, 95% confidence interval: 1.99-7.63), kidney failure (odds ratio: 1.90, 95% confidence interval: 1.32-2.74), and in-hospital mortality (odds ratio: 2.17, 95% confidence interval: 1.30-3.60).

CONCLUSION

TDC-C serves as a predictive factor for complications following coronary artery bypass grafting. We strongly recommend that future studies incorporate this metric to improve the prediction of complications.

Perioperative Characteristics and Outcomes of Fontan Versus Non-Fontan Patients Undergoing Combined Heart-Liver Transplantation: A Retrospective Cohort Study

OBJECTIVES

Combined heart-liver transplantation (CHLT) is becoming increasingly frequent as a maturing population of patients with Fontan-palliated congenital heart disease develop advanced liver fibrosis or cirrhosis. The authors present their experience with CHLT for congenital and noncongenital indications, and identify characteristics associated with poor outcomes that may guide intervention in high-risk patients.

DESIGN

This was a single-center retrospective cohort study.

SETTING

This study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee.

PARTICIPANTS

The study included 16 consecutive adult recipients of CHLT at the authors' institution between April 2017 and February 2022.

INTERVENTIONS

Eleven patients underwent transplantation for Fontan indications, and 5 were transplanted for non-Fontan indications.

MEASUREMENTS AND MAIN RESULTS

Compared with non-Fontan patients, Fontan recipients had longer cardiopulmonary bypass duration (199 v 119 minutes, p =m0.002), operative times (786 v 599 minutes, p = 0.01), and larger blood product transfusions (15.4 v 6.3 L, p = 0.18). Six of 16 patients required extracorporeal membrane oxygenation (ECMO), of whom 4 were Fontan patients who subsequently died. Patients who required ECMO had lower 5-hour lactate clearance (0.0 v 3.5 mmol/L, p = 0.001), higher number of vasoactive infusions, lower pulmonary artery pulsatility indices (0.58 v 1.77, p = 0.03), and higher peak inspiratory pressures (28.0 v 18.5 mmHg, p = 0.01) after liver reperfusion.

CONCLUSIONS

Combined heart-liver transplantation in patients with Fontan-associated end-organ disease is particularly challenging and associated with higher recipient morbidity compared with non-Fontan-related CHLT. Early hemodynamic intervention for signs of ventricular dysfunction may improve outcomes in this growing high-risk population.

Cardiopulmonary bypass management and acute kidney injury in cardiac surgery patients

BACKGROUND

Cardiopulmonary bypass (CPB) ensures tissue oxygenation during cardiac surgery. New technology allows continuous registration of CPB variables during the operation. The aim of the present investigation was to study the association between CPB management and the risk of postoperative acute kidney injury (AKI).

METHODS

This observational study based on prospectively registered data included 2661 coronary artery bypass grafting and/or valve patients operated during 2016-2020. Individual patient characteristics and postoperative outcomes collected from the SWEDEHEART registry were merged with CPB variables automatically registered every 20 s during CPB. Associations between CPB variables and AKI were analyzed with multivariable logistic regression models adjusted for patient characteristics.

RESULTS

In total, 387 patients (14.5%) developed postoperative AKI. After adjustments, longer time on CPB and aortic cross-clamp, periods of compromised blood flow during aortic cross-clamp time, and lower nadir hematocrit were associated with the risk of AKI, while mean blood flow, bladder temperature, central venous pressure, and mixed venous oxygen saturation were not. Patient characteristics independently associated with AKI were advanced age, higher body mass index, hypertension, diabetes mellitus, atrial fibrillation, lower left ventricular ejection fraction, estimated glomerular filtration rate <60 or >90 mL/min/m2 , and preoperative hemoglobin concentration below or above the normal sex-specific range.

CONCLUSIONS

To reduce the risk of AKI after cardiac surgery, aortic clamp time and CPB time should be kept short, and low hematocrit and periods of compromised blood flow during aortic cross-clamp time should be avoided if possible.

Procedural selection strategy and clinical outcomes in mitral valve surgery with concomitant aortic valve replacement in elderly patients

Introduction

In the context of double-valve surgery for elderly high-risk patients involving both the aortic and mitral valves, a clinically significant problem has been that no clear criteria or surgical strategies have been reported for the selection of mitral valve plasty (MVP) or mitral valve replacement (MVR) for mitral valve disease management during surgical aortic valve replacement (SAVR) to achieve better clinical outcomes. This study investigated valve durability and survival using our surgical strategy for mitral valve disease with concomitant SAVR in elderly patients.

Methods

Eighty-six patients aged > 65 years (mean 75 years) who underwent a double-valve procedure for mitral valve surgery with concomitant SAVR from 2010 to 2022 were reviewed. Our surgical strategy for mitral valve disease with concomitant SAVR for the elderly patients was as follows: MVP was selected for patients in whom mitral valve disease was expected to be controlled with simple surgical procedures (n = 47), otherwise MVR was selected (n = 39).

Results

The hospital mortality rate was 8% (n = 7). The mean follow-up was 4.9 (0-12.3) years. And the 10-year survival rate was 62%. The 10-year freedom from aortic valve reoperation rate was 95%. No mitral valve reintervention was performed during follow-up. Echocardiographic follow-up demonstrated freedom from at least moderate mitral regurgitation in 86% of cases at 10 years.

Conclusion

In double-valve surgery for elderly high-risk patients, appropriate selection of the mitral valve procedure with concomitant SAVR provided better early and long-term survival and valve durability. This surgical strategy may be beneficial in elderly patients with combined aortic and mitral valve disease.

Perceval sutureless bioprosthesis versus Perimount sutured bioprosthesis for aortic valve replacement in patients with aortic stenosis: a retrospective, propensity-matched study

BACKGROUND

Rapid-deployment aortic valve replacement (RDAVR) is an alternative to conventional AVR (cAVR) for aortic stenosis. Benefits include a reduction in operative times, facilitation of minimal access surgery and superior haemodynamics compared to conventional valves. However, further evidence is required to inform guidelines, preferably in the form of propensity-matched studies that include mid-term follow-up data.

METHODS

This was a single-centre, retrospective, propensity-matched cohort study comparing the Perceval and conventional Perimount Magna Ease valve for short- and mid-term clinical parameters and size-matched mid-term echocardiographic parameters (n = 102 in both groups) from 2014 to 2020. Data were extracted from a nationally managed dataset.

RESULTS

There were no demographic differences between the matched groups. The Perceval group had shorter cross-clamp time (Perceval 62 [49-81] minutes; Perimount 79 [63-102] minutes, P < 0.001), shorter bypass time (Perceval 89 [74-114] minutes; Perimount 104 [84-137] minutes, P < 0.001), and more frequent minimally-invasive approaches (Perceval 28%; Perimount 5%, P < 0.001). Size-matched haemodynamics showed initially higher gradients in the Perceval group, but haemodynamics equalised at 12 + months. The Perceval group had a more favourable % change in the left ventricular posterior wall dimension at 2 + years (Perceval - 4.8 ± 18; Perimount 17 ± 2).

CONCLUSIONS

The Perceval facilitated shorter operations, which may benefit intermediate-high-risk, elderly patients with comorbidities requiring concomitant procedures. It also facilitated minimally invasive surgery. Size-matched haemodynamic performance was similar at mid-term follow-up, with the Perceval possibly better facilitating regression of left ventricular hypertrophy.

Innovations in Aortic Valve Replacement: A Comprehensive Overview of the Intuity Rapid Deployment Valve

Rapid deployment/sutureless (RDS) valves have recently emerged as an innovative surgical solution, providing an alternative to traditional methods of surgical aortic valve replacement (SAVR) by eliminating the need for suture placement and tying. This innovation leads to a reduction in aortic crossclamp and cardiopulmonary bypass times, enhancing the efficiency of the procedure. Among the 2 available RDS valves, the Edwards Intuity valve in particular has been demonstrated to be a particularly promising substitute in the field of SAVR. The Intuity valve distinguishes itself from other RDS and conventional valves by yielding superior outcomes, such as a significant reduction in mortality, increase in the longevity of the valve, and a marked decrease in both mean and peak transvalvular pressure gradients. These benefits collectively contribute to its appeal as a favorable new solution. However, further investigation is needed to conclusively determine the long-term outcomes and safety of RDS valves. Nevertheless, the utilization of the Intuity valve presents an exciting solution to the existing limitations of conventional and minimally invasive SAVR, especially for patients afflicted with severe aortic stenosis.

Transcatheter aortic valve implantation versus sutureless aortic valve replacement: a single-centre cost analysis

AIMS

Sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve implantation (TAVI) are both viable therapeutic interventions for aortic stenosis in elderly patients. Meta-analyses show similar all-cause mortality for both techniques albeit with a different pattern of adverse effects. This study means to compare costs and, to a lesser extent, clinical outcomes of both techniques.

METHODS

A retrospective single-centre analysis was performed for patients receiving SU-AVR or TAVI from 2008 to 2019. Perioperative clinical data were collected from patient files. Costs were assessed by a cost allocation tool. In an attempt to avoid confounding, propensity score matching was carried out.

RESULTS

A total of 368 patients underwent either TAVI (n = 100) or SU-AVR (n = 268). After matching, there were 61 patients per treatment group. Length of stay was significantly longer in the SU-AVR group. Excluding device costs, total expenses for SU-AVR (median: €11,630) were significantly higher than TAVI (median: €9240). For both groups, these costs were mostly incurred on intensive care units, followed by nursing units. Non-medical staff was the largest contributor to expenses. Including device costs, SU-AVR (median: €14,683) was shown to be cost-saving compared to TAVI (median: €24,057).

CONCLUSIONS

To conclude, we found SU-AVR to be cost-saving compared to TAVI, largely due to higher device costs associated with the latter. Excluding device costs, TAVI was associated with lower expenses and shorter length of stay. Non-medical staff was the largest source of costs, suggesting length of stay to be a major financial determinant.

Clinical Outcomes after Multivalve Surgery in Octogenarians: Evaluating the Need for a Paradigm Shift

(1) Background: this study addresses the lack of comprehensive research on outcomes in octogenarians undergoing cardiac surgery for multivalvular disease, emphasizing the need for a critical examination of the intervention's overall worth in this aging population. (2) Methods: By analyzing short-term and mid-term data from 101 consecutive octogenarian patients undergoing multivalve surgery, the study identifies predictors for in-hospital and one-year mortality. (3) Results: In-hospital mortality increased fourfold with the occurrence of at least one postoperative complication. Octogenarians undergoing multivalve surgery experienced an in-hospital mortality rate of 13.9% and an overall one-year mortality rate of 43.8%. Postoperative delirium was identified as an independent risk factor, contributing to elevated risks of both in-hospital and one-year mortality. Prolonged surgical procedure time emerged as an independent risk factor associated with increased in-hospital mortality. Continuous veno-venous hemodialysis showed an independent impact on in-hospital mortality. Both re-intubation and the transfusion of packed red blood cells were identified as independent risk factors for one-year mortality. (4) Conclusions: This study urges a critical examination of the justification for multivalve surgeries in high-risk elderly patients, emphasizing a paradigm shift. It advocates for interdisciplinary collaboration and innovative strategies, such as staged hybrid procedures, to improve therapeutic approaches for this challenging patient group to achieve a better therapeutic outcome for these patients.

Sutureless Biological Aortic Valve Replacement (Su-AVR) in Redo operations: a retrospective real-world experience report of clinical and echocardiographic outcomes

OBJECTIVE

This retrospective study aimed to compare the outcomes of sutureless aortic valve replacement (su-AVR) and conventional bioprosthetic sutured AVR (cAVR) in high-risk patients undergoing redo surgery.

METHODS

A total of 79 patients who underwent redo AVR between 2014 and 2021 were included in the study. Of these, 27 patients underwent su-AVR and 52 underwent cAVR. Patient characteristics and clinical outcomes were analysed using multivariate regression and Kaplan Meier survival test.

RESULTS

The groups were similar in terms of age, gender, left ventricular function, and number of previous sternotomies. In cases of isolated AVR, su-AVR had significantly lower cross clamp times than cAVR (71 vs. 86 min, p = 0.03). Postoperatively, 4 cAVR patients required pacemaker compared to zero patients in the su-AVR group. There were no significant differences between the two groups in terms of postoperative complications, intrahospital stay (median 9 days, IQR 7-20), or in-hospital mortality (1 su-AVR; 2 cAVR). The long-term survival rate was similar between the su-AVR (90%) and cAVR (92%) groups (log rank p = 0.8). The transvalvular gradients at follow-up were not affected by the type of valve used, regardless of the valve size (coef 2.68, 95%CI -3.14-8.50, p = 0.36).

CONCLUSION

The study suggests that su-AVR is a feasible and safe alternative to cAVR in high-risk patients undergoing redo surgery. The use of su-AVR offers comparable outcomes to cAVR, with reduced cross clamp times and a lower incidence of postoperative pacemaker requirement in isolated AVR cases. The results of this study contribute to the growing body of evidence supporting the use of su-AVR in high-risk patients, highlighting its feasibility and safety in redo surgeries.

Elderly patients benefit from minimally invasive mitral valve surgery: perioperative risk management matters

OBJECTIVES

The goal was to assess the single-centre results of minimally invasive mitral valve surgery (MIMVS) in the elderly population.

METHODS

All patients referred for minimally invasive valve surgery underwent a standardized preoperative screening. We performed a retrospective analysis of 131 consecutive elderly patients (≥75 years) who underwent endoscopic MIMVS through a right mini-thoracotomy. Survival and postoperative course were assessed in 2 groups: a repair group and a replacement group.

RESULTS

Eighty-five patients underwent mitral valve repair, and 46 had mitral valve replacement. The mean age was 79 ± 2.9 years, and the median follow-up duration was 3.8 years. The cardiopulmonary bypass time (128.7 min vs 155.9 min, P = 0.012) and the cross-clamp time (84.9 min vs 124.1 min, P = 0.005) were significantly longer in the replacement group. Except for more reinterventions for bleeding in the replacement group (10.9% vs 0%, P = 0.005), there were no significant differences in the postoperative course between the 2 groups. Low mortality rates at the midterm follow-up were observed in both groups, and no differences were observed between the 4-and the 12-month follow-up. Survival rates after 1 year and 5 years were 97.6% and 88.6%, respectively, with no significant differences between the 2 groups.

CONCLUSIONS

MIMVS is an excellent treatment option in vulnerable elderly patients with excellent short- and long-term results. Although other studies suggest that repair could be superior to replacement even in older patients, our experience suggests that replacement is equivalent to repair in terms of mortality and major adverse cardiac and cerebrovascular events. Experience and standardized preoperative screening are mandatory to achieve optimal results.

The Northern New England Rapid Deployment Valve Experience: Survival and Procedural Outcomes From 2015 to 2021

OBJECTIVE

The optimal approach and choice of initial aortic valve replacement (AVR) is evolving in the growing era of transcatheter AVR. Further survival and hemodynamic data are needed to compare the emerging role of rapid deployment (rdAVR) versus stented (sAVR) valve options for AVR.

METHODS

The Northern New England Cardiovascular Database was queried for patients undergoing either isolated AVR or AVR + coronary artery bypass grafting (CABG) with rdAVR or sAVR aortic valves between 2015 and 2021. Exclusion criteria included endocarditis, mechanical valves, dissection, emergency case status, and prior sternotomy. This resulted in a cohort including 1,616 sAVR and 538 rdAVR cases. After propensity weighting, procedural characteristics, hemodynamic variables, and survival outcomes were examined.

RESULTS

The breakdown of the overall cohort (2,154) included 1,164 isolated AVR (222 rdAVR, 942 sAVR) and 990 AVR + CABG (316 rdAVR, 674 sAVR). After inverse propensity weighting, cohorts were well matched, notable only for more patients <50 years in the sAVR group (4.0% vs 1.9%, standardized mean difference [SMD] = -0.12). Cross-clamp (89 vs 64 min, SMD = -0.71) and cardiopulmonary bypass (121 vs 91 min, SMD = -0.68) times were considerably longer for sAVR versus rdAVR. Immediate postreplacement aortic gradient decreased with larger valve size but did not differ significantly between comparable sAVR and rdAVR valve sizes or overall (6.5 vs 6.7 mm Hg, SMD = 0.09). Implanted rdAVR tended to be larger with 51% either size L or XL versus 37.4% of sAVR ≥25 mm. Despite a temporal decrease in pacemaker rate within the rdAVR cohort, the overall pacemaker frequency was less in sAVR versus rdAVR (4.4% vs 7.4%, SMD = 0.12), and significantly higher rates were seen in size L (10.3% vs 3.7%, P < 0.002) and XL (15% vs 5.6%, P < 0.004) rdAVR versus sAVR. No significant difference in major adverse cardiac events (4.6% vs 4.6%, SMD = 0.01), 30-day survival (1.5% vs 2.6%, SMD = 0.08), or long-term survival out to 4 years were seen between sAVR and rdAVR.

CONCLUSIONS

Rapid deployment valves offer a safe alternative to sAVR with significantly decreased cross-clamp and cardiopulmonary bypass times. Despite larger implantation sizes, we did not appreciate a comparative difference in immediate postoperative gradients, and although pacemaker rates are improving, they remain higher in rdAVR compared with sAVR. Longer-term hemodynamic and survival follow-up are needed.

Impact of Previous Cardiac Operations in Patients Undergoing Surgery for Type A Acute Aortic Dissection. Long-Term Follow Up

Aim of this multicenter study was to evaluate the impact of reoperative cardiac surgery for type A acute aortic dissection (TAAAD) on early and long-term outcomes. Patients with history of previous cardiac surgery were included in group R while those undergoing first operation where included in group F. Kaplan-Meier analysis was used to evaluate long-term survival in the 2 groups. A total of 1472 patients were included in the analysis. Of these, 85 (5.8%) and 1387 (94.2%) were included in group R and F, respectively. Thirty-day mortality was 24% (20 patients) and 18% (249 patients) in groups R and F, respectively(P = 0.8). Kaplan-Meier survival at 10 and at 20-year was 51.5% and 30.2% in group R and 48% and 32% in group F (P = 0.368). Patients with a history of previous cardiac operations who develop TAAAD can undergo surgery with similar early and long-term outcomes compared to those at their first operation.

Double-layer horizontal cross sutures for intra-atrial mitral valve implantation: An effective surgical method for severe mitral annular calcification

Objective

Severe mitral annular calcification (MAC) can make prosthetic implantation extremely difficult. Although intra-atrial mitral valve prosthesis implantation without annular decalcification offers a simpler approach, it poses a potential rupture risk due to high left ventricular pressure. We developed a double-layer (DL) horizontal cross-suture technique, which ensures close proximity of the valve prosthesis to the calcified annulus and segregates the left atrial wall from the left ventricle. The aim of this study was to compare the outcomes of DL suture with conventional single-layer (SL) suture in patients with severe MAC.

Methods

This retrospective cohort study consecutively enrolled patients with severe MAC undergoing mitral valve replacement at Beijing Anzhen Hospital from May 2018 to December 2022. A detailed description of the DL suture method is described. Follow-up medical evaluations, including transthoracic echocardiography measurements, were obtained through outpatient chart reviews.

Results

The study included 10 patients in the DL suture group and 20 in the SL suture group. All patients in the DL group and all but 3 in the SL group achieved technical success. Compared with the SL group, the DL suture technique was associated with lower rates of perivalvular leakage, stroke, new-onset atrial fibrillation, reoperation, and 30-day mortality. Follow-up was complete, with 1 late mortality in the DL group due to stroke and 4 cardiovascular deaths in the SL group.

Conclusions

The DL horizontal cross-suture technique offers a more effective and safer approach for intra-atrial mitral valve implantation in severe MAC cases than the conventional SL suture method.

Risk factors of in-hospital mortality for isolated on-pump coronary artery bypass graft surgery in the northeast of Iran from 2007 to 2016

BACKGROUND AND OBJECTIVE

Coronary artery bypass graft (CABG) surgery is the most common cardiac surgery worldwide. The reported mortality rates for this operation vary greatly. We aimed to determine the risk factors of in-hospital mortality for isolated on-pump CABG surgery.

METHODS

This was a large-scale retrospective cohort study of two heart centers in Golestan province. Patients over the age of 18 from both genders who underwent isolated on-pump CABG procedures from 2007 to 2016 were included. The study outcome was in-hospital mortality, which was determined according to the clinical records of study patients.

RESULTS

A total of 3704 patients were included in the study, and 63% were men. In-hospital mortality occurred in 2.8% (n=103) of the patients. The median (IQR) age of survived and not-survived patients were 59 (53-65) and 62 (55-75) years, respectively. 44% of the mortalities occurred in patients older than 65, while 28% of the survivors were older than 65. Multivariable logistic regression indicated that emergency CABG (OR 4.52, 95% CI, 1.45, 14.02; P = 0.009) and cardiopulmonary bypass time (CPB) (OR 1.004, 95% CI 1.001, 1.008; P = 0.034) were the risk factors of in-hospital mortality. The area under the receiver operating characteristic (ROC) curve (AUC) of the model consisting of operative and preoperative variables was 0.70 (acceptable performance).

CONCLUSION

Our study revealed an acceptable mortality proportion for CABG surgeries conducted in the region. Emergency CABG and CPB time were the main risk factors for in-hospital mortality after CABG.

Quantifying the effects of circulatory arrest on acute kidney injury in aortic surgery

OBJECTIVES

We aim to investigate the association between parameters surrounding circulatory arrest and postoperative acute kidney injury in aortic surgery.

METHODS

This is a single-center retrospective study of 1118 adult patients who underwent aortic repair with median sternotomy between January 2010 and May 2019. Acute kidney injury was defined on the basis of a modified version of the 2012 Kidney Disease Improving Global Outcomes Scale that excluded urine output. The primary outcome of interest was any stage of acute kidney injury.

RESULTS

Circulatory arrest was required in 369 patients, and 307 patients (27.5%) developed acute kidney injury: stage 1 in 241 patients, stage 2 in 38 patients, and stage 3 in 28 patients. Lower-body ischemia (the period during circulatory arrest without blood flow to kidneys) duration was not associated with acute kidney injury after multivariable logistic regression (1-40 minutes, odds ratio, 0.67; 95% confidence interval, 0.43-1.04; P = .075; >40 minutes, odds ratio, 0.67; 95% confidence interval, 0.29-1.55; P = .356). Hypertension (odds ratio, 1.65; 95% confidence interval, 1.09-2.54; P = .020), preoperative estimated glomerular filtration rate (odds ratio, 0.99; 95% confidence interval, 0.98-1.00; P = .010), packed red blood cell transfusion volume (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .028), and nadir temperature (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .013) were independently associated with acute kidney injury after multivariable analysis. Although there was a positive association between lower-body ischemia duration and development of acute kidney injury with univariable cubic spline, the positive curve was flattened after adjustment for the described variables.

CONCLUSIONS

Within the range of our clinical practice, prolonged lower-body ischemia duration was not independently associated with postoperative acute kidney injury, whereas nadir temperature was.

Central vs. Peripheral Cannulation During Reoperations: A Propensity Score Matching Analysis

INTRODUCTION

The aim of this study is to compare the postoperative outcomes and early mortality of peripheral and central cannulation techniques in cardiac reoperations using propensity score matching analysis.

METHODS

In this retrospective cohort, patients who underwent cardiac reoperations with median resternotomy were analyzed in terms of propensity score matching. Between November 2010 and September 2020, 257 patients underwent cardiac reoperations via central (Group 1) or peripheral (Group 2) cannulation. A 1:1 propensity score matching was performed to balance the influence of potential confounding factors to compare postoperative data and mortality rate.

RESULTS

There were no significant differences when comparing the matched groups regarding early mortality (P=0.51), major cardiac injury (P=0.99), prolonged ventilation (P=0.16), and postoperative stroke (P=0.99). The development of acute renal failure (P=0.02) was statistically less frequent in Group 1.

CONCLUSIONS

Performing cardiopulmonary bypass via peripheral cannulation increases acute renal failure in cardiac reoperations. In contrast, peripheral or central cannulation have similar early mortality rate in cardiac reoperations.

Impact of Previous Conventional Cardiac Surgery on the Clinical Outcomes After Heart Transplantation

The impact of the type, purpose, and timing of prior surgery on heart transplantation (HT) remains unclear. This study investigated the influence of conventional cardiac surgery (PCCS) on HT outcomes. This study analyzed HTs performed between 1999 and 2019 at a single institution. Patients were categorized into two groups: those with and without PCCS. Short-term outcomes, including post-transplant complications and mortality rates, were evaluated. Cox proportional and Kaplan-Meier survival analyses were used to identify risk factors for mortality and assess long-term survival, respectively. Of 368 patients, 29% had PCCS. Patients with PCCS had a higher incidence of post-transplant complications. The in-hospital and 1 year mortality rates were higher in the PCCS group. PCCS and cardiopulmonary bypass time were significant risk factors for 1 year mortality (hazard ratios = 2.485 and 1.005, respectively). The long-term survival rates were lower in the PCCS group, particularly in the first year. In sub-analysis, patients with ischemic cardiomyopathy and PCCS had the poorest outcomes. The era of surgery and timing of PCCS in relation to HT did not significantly impact outcomes. In conclusion, PCCS worsen the HT outcomes, especially in patients with ischemic etiology. However, the timing of PCCS and era of HT did not significantly affect this concern.

Cardiac reverse remodeling in primary mitral regurgitation: mitral valve replacement vs. mitral valve repair

BACKGROUND

When feasible, guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) to treat primary mitral regurgitation (MR), based upon historic outcome studies and transthoracic echocardiography (TTE) reverse remodeling studies. Cardiovascular magnetic resonance (CMR) offers reference standard biventricular assessment with superior MR quantification compared to TTE. Using serial CMR in primary MR patients, we aimed to investigate cardiac reverse remodeling and residual MR post-MVr vs MVR with chordal preservation.

METHODS

83 patients with ≥ moderate-severe MR on TTE were prospectively recruited. 6-min walk tests (6MWT) and CMR imaging including cine imaging, aortic/pulmonary through-plane phase contrast imaging, T1 maps and late-gadolinium-enhanced (LGE) imaging were performed at baseline and 6 months after mitral surgery or watchful waiting (control group).

RESULTS

72 patients completed follow-up (Controls = 20, MVr = 30 and MVR = 22). Surgical groups demonstrated comparable baseline cardiac indices and co-morbidities. At 6-months, MVr and MVR groups demonstrated comparable improvements in 6MWT distances (+ 57 ± 54 m vs + 64 ± 76 m respectively, p = 1), reduced indexed left ventricular end-diastolic volumes (LVEDVi; - 29 ± 21 ml/m2 vs - 37 ± 22 ml/m2 respectively, p = 0.584) and left atrial volumes (- 23 ± 30 ml/m2 and - 39 ± 26 ml/m2 respectively, p = 0.545). At 6-months, compared with controls, right ventricular ejection fraction was poorer post-MVr (47 ± 6.1% vs 53 ± 8.0% respectively, p = 0.01) compared to post-MVR (50 ± 5.7% vs 53 ± 8.0% respectively, p = 0.698). MVR resulted in lower residual MR-regurgitant fraction (RF) than MVr (12 ± 8.0% vs 21 ± 11% respectively, p = 0.022). Baseline and follow-up indices of diffuse and focal myocardial fibrosis (Native T1 relaxation times, extra-cellular volume and quantified LGE respectively) were comparable between groups. Stepwise multiple linear regression of indexed variables in the surgical groups demonstrated baseline indexed mitral regurgitant volume as the sole multivariate predictor of left ventricular (LV) end-diastolic reverse remodelling, baseline LVEDVi as the most significant independent multivariate predictor of follow-up LVEDVi, baseline indexed LV end-systolic volume as the sole multivariate predictor of follow-up LV ejection fraction and undergoing MVR (vs MVr) as the most significant (p < 0.001) baseline multivariate predictor of lower residual MR.

CONCLUSION

In primary MR, MVR with chordal preservation may offer comparable cardiac reverse remodeling and functional benefits at 6-months when compared to MVr. Larger, multicenter CMR studies are required, which if the findings are confirmed could impact future surgical practice.

Prognostic Factors for Postoperative Bleeding Complications and Prolonged Intensive Care after Percutaneous Hepatic Chemosaturation Procedures with Melphalan

Percutaneous hepatic melphalan perfusion (chemosaturation) in patients with liver metastases is known to be associated with procedure-related hemodynamic depression and coagulation impairment, which may cause bleeding complications and/or a prolonged intensive care unit length of stay (ICU LOS). We retrospectively analyzed possible predictive factors for bleeding complications and an ICU LOS > 1 d in a cohort of 31 patients undergoing 90 chemosaturation procedures. Using a multivariable mixed-model approach, we identified the amount of perioperative fluid volume (OR 12.0, 95% CI 2.3-60.0, p = 0.003) and protamine (OR 0.065, 95% CI 0.007-0.55, p = 0.012) to be associated with bleeding complications. Furthermore, the amount of perioperative fluid volume was associated with an ICU LOS > 1 d (OR 5.2, 95% CI 1.4-19.0, p = 0.011). Heparin dosage, melphalan dosage, extracorporeal circulation time, and noradrenaline dosage had no significant effects on outcomes. Protamine use was not associated with anaphylactic or thromboembolic complications. Despite the limited sample size, these results suggest a restrictive perioperative fluid regime to be beneficial, and support the use of protamine for heparin reversal after chemosaturation procedures. Further prospective randomized trials are needed to confirm these findings.

Single-Center Real-World Experience with Sutureless Aortic Valve Prosthesis in Isolated and Combined Procedures

INTRODUCTION

Due to their favourable hemodynamic performance and the ability to enable minimally invasive access procedures, sutureless aortic valve prostheses have found their place in the armamentarium of cardiothoracic surgeons. In this study, we sought to review our institutional experience of sutureless aortic valve replacement (SU-AVR).

METHODS

We carried out a retrospective analysis of 200 consecutive patients who underwent an SU-AVR with a Perceval valve between December 2019 and February 2023.

RESULTS

The mean age of patients was 69.3 ± 8.1 years, and patients showed a moderate-risk profile with a mean logistic EuroSCORE-II of 5.2 ± 8.1%. An isolated SU-AVR was performed in 85 (42.5%) patients, concomitant CABG was performed in 75 (37.5%) and 40 patients (20%) underwent a multivalve procedure involving SU-AVR. The cardiopulmonary bypass (CPB) and cross-clamp (CC) times were 82.1 ± 35.1 and 55.5 ± 27.8 min, respectively. In-hospital, 30-day, 6-month and 1-year mortality rates were 4.5%, 6.5%, 7.5% and 8.2%, respectively. The postoperative transvalvular mean pressure gradient was 6.3 ± 1.6 mmHg and stayed stable over the follow-up time. We reported no cases of paravalvular leakage, and the incidence of stroke was 0.5%.

CONCLUSIONS

With their favourable hemodynamic performance and shorter CC and CPB times, sutureless aortic valve prostheses facilitate minimally invasive access surgery, being a safe and durable promising approach for the surgical AVR.

Predictors of Mediastinal Exploration While on Extracorporeal Membrane Oxygenation After Pediatric Cardiac Surgery

Cardiac surgical patients requiring extracorporeal membrane oxygenation (ECMO) are at increased risk for hemorrhage due to necessary anticoagulation, in-situ cannulas, and disturbed hemostasis. We performed a retrospective, cross-sectional study of patients 0-18 years old in our cardiac intensive care unit (CICU) cannulated to ECMO within 48 h of cardiopulmonary bypass. The 69 patients included in the study were divided into three analysis groups based on serial chest tube output per hour: no bleeding (NB) on admission to the CICU (21/69, 30%), bleeding stopped (BS) with medical management (26/69, 38%), bleeding requiring emergent mediastinal exploration (BME) (22/69, 32%). The NB group had a more favorable coagulation profile upon admission to the CICU (PTT 53 s NB, 105 s BS, 83 s BME p < 0.001, ACT 169 s NB, 225 s BS, 211 s BME, p =0.013). Only chest tube output during the first three postcannulation hours remained associated with the need for mediastinal exploration by multivariable analysis. An average chest-tube output of 11.6 mL/kg/h during the first three hours had the highest percentage of patients classified correctly (84%) for requiring mediastinal exploration during their ECMO run (sensitivity 91%, specificity 81%).

Operative Teaching of Coronary Bypass and Need for Repeat Catheterization: Does it Matter Who is Sewing?

OBJECTIVE

There are no studies to date comparing the patency of coronary bypass grafts constructed by attending surgeons versus trainees and the potential consequences of any such disparities. We explored this issue by comparing the patency of individual anastomoses performed by residents versus the attending surgeon.

DESIGN

We reviewed 765 continuous cases performed by a single surgeon which involved at least 1 coronary bypass anastomosis, totaling 2,173 distal anastomoses. At a median follow-up time of 36 months (interquartile range 20.5-47.3), 83 (10.9%) patients had undergone 110 cardiac catheterization procedures after their original operation for various indications. This angiographic information provided the data for our comparison cohorts.

SETTING

Cardiac surgery practice within an academic setting PARTICIPANTS: Adult patient undergoing coronary bypass grafting RESULTS: Of the 83 patients that underwent repeat catheterization, 23 (27.7%) were resident cases, 25 (30.1%) were attending cases and 35 (42.2%) were mixed. There were 4/83 (4.8%) patients with angiographic evidence of internal mammary artery graft compromise of which 3/4 (75%) had been constructed by the attending surgeon. Angiographic evidence of saphenous vein graft compromise was appreciated in 16/83 (19.3%) patients of which 9/16 (56.3%) of the grafts were constructed by the attending surgeon.

CONCLUSIONS

Liberal involvement of surgical trainees as primary operators in coronary revascularization cases led to equivalent rates of postoperative ischemic complications between the attending and resident groups. The outcome equivalence was also maintained when evaluated at the individual anastomosis patency level between the 2 groups. We conclude that academic programs should continue providing trainees significant experience as primary operating surgeons without fear of clinical outcome compromise.

A tool to assess nontechnical skills of perfusionists in the cardiac operating room

OBJECTIVES

This study aimed to develop the Perfusionists' Intraoperative Non-Technical Skills tool, specifically to the perfusionists' context, and test its inter-rater reliability.

METHODS

An expert panel was convened to review existing surgical nontechnical skills taxonomies and develop the Perfusionists' Intraoperative Non-Technical Skills tool. During a workshop held at a national meeting, perfusionists completed the Perfusionists' Intraoperative Non-Technical Skills ratings after watching 4 videos displaying simulated cardiac operations. Two videos showed "good performance," and 2 videos showed "poor performance." Inter-rater reliability analysis was performed and intraclass correlation coefficient was reported.

RESULTS

The final version of the Perfusionists' Intraoperative Non-Technical Skills taxonomy contains 4 behavioral categories (decision making, situation awareness, task management and leadership, teamwork and communication) with 4 behavioral elements each. Categories and elements are rated using an 8-point Likert scale ranging from 0.5 to 4.0. A total of 60 perfusionist raters were included and the comparison between rating distribution on "poor performance" and "good performance" videos yielded a statistically significant difference between groups, with a P value less than .001. A similar difference was found in all behavioral categories and elements. Reliability analysis showed moderate inter-rater reliability across overall ratings (intraclass correlation coefficient, 0.735; 95% confidence interval, 0.674-0.796; P < .001). Similar inter-rater reliability was found when raters were stratified by experience level.

CONCLUSIONS

The Perfusionists' Intraoperative Non-Technical Skills tool presented moderate inter-rater reliability among perfusionists with varied levels of experience. This tool can be used to train and assess perfusionists in relevant nontechnical skills, with the potential to enhance safety and improve surgical outcomes.