Long-term outcomes for hybrid aortic arch repair

OBJECTIVE

Since its inception in the early 2000s, hybrid arch repair (HAR) has evolved from novel approach to well-established treatment modality for aortic arch pathology in appropriately selected patients. Despite this nearly 20-year history of use, long-term results of HAR remain to be determined. As such, objectives of this study are to detail the long-term outcomes for HAR within an expanded classification scheme.

METHODS

From August 2005 to August 2022, 163 consecutive patients underwent HAR at a single referral institution. Operative approach was selected according to an institutional algorithm and included zone 0/1 HAR in 25% (n = 40), type I HAR in 34% (n = 56), and type II/III HAR in 41% (n = 67). Specific zone 0/1 technique was zone 1 HAR in 31 (78%), zone 0 with innominate snorkel (zone 0S HAR) in 7 (18%), and zone 0 with single side-branch endograft (zone 0B HAR) in 2 (5%). The 30-day and long-term outcomes, including overall and aortic-specific survival, as well as freedom from reintervention, were assessed.

RESULTS

The mean age was 63 ± 13 years and almost one-half of patients (47% [n = 77]) had prior sternotomy. Presenting pathology included degenerative aneurysm in 44% (n = 71), residual dissection after prior type A repair in 38% (n = 62), chronic type B dissection in 12% (n = 20), and other indications in 6% (n = 10). Operative outcomes included 9% mortality (n = 14) at 30 days, 5% mortality (n = 8) in hospital, 4% stroke (n = 7), 2% new dialysis (n = 3), and 2% permanent paraparesis/plegia (n = 3). The median follow-up was 44 month (interquartile range, 12-84 months). Overall survival was 59% and 47% at 5 and 10 years, respectively, whereas aorta-specific survival was 86% and 84% at the same time points. At 5 and 10 years, freedom from major reintervention was 92% and 91%, respectively. Institutional experience had a significant impact on both early and late outcomes: comparing the first (2005-2012) and second (2013-2022) halves of the series, 30-day mortality decreased from 14% to 1% (P = .01) and stroke from 6% to 3% (P = .62). Improved operative outcomes were accompanied by improved late survival, with 78% of patients in the later era vs 45% in the earlier era surviving to 5 years.

CONCLUSIONS

HAR is associated with excellent operative outcomes, as well as sustained protection from adverse aortic events as evidenced by high long-term aorta-specific survival and freedom from reintervention. However, surgeon and institutional experience appear to play a major role in achieving these superior outcomes, with a five-fold decrease in operative mortality and a two-fold decrease in stroke rate in the latter half of the series. These long-term results expand on prior midterm data and continue to support use of HAR for properly selected patients with arch disease.

Mid-term outcomes of aortic valve repair using an anatomically shaped internal annuloplasty ring

OBJECTIVES

The Hemispherical Aortic Annuloplasty Reconstructive Technology (HAART) ring is a rigid, internal and geometric device. The objective of this article is to assess the mid-term outcomes of aortic valve repair (AVr) using this prosthesis.

METHODS

A prospectively maintained database was used to obtain outcomes for adult patients undergoing AVr using the HAART ring between September 2017 and June 2023. All aortic patients at our institution undergo life-long surveillance with regular assessment and valve imaging.

RESULTS

Seventy-one patients underwent AVr using the HAART device: 53 had a trileaflet valve and 18 a bicuspid valve. The median age was 54 years, and most were male (79%). Many required concomitant intervention: 46% had a root procedure and 77% an arch repair. There were no in-hospital deaths, and the median postoperative stay was 5 days. At a mean follow-up of 3.9 (±1.1) years, freedom from reoperation was 94%. Late imaging demonstrated: zero trace (25%), 1+ (54%), 2+ (15%) and 4+ (6%) aortic insufficiency (AI). Eleven patients have ≥moderate AI under surveillance, all of whom have a trileaflet valve (21% of trileaflet patients). Four patients required reoperation: 3 for ring dehiscence and 1 for endocarditis.

CONCLUSIONS

Although early results using the HAART device are encouraging, mid-term results raise concern as 21% of trileaflet patients developed recurrent ≥moderate AI by 4 years post-repair. We experienced 3 incidences of ring dehiscence requiring reoperation. Based on this, we recommend caution using the sub-annular approach for stabilization in patients with trileaflet aortic valves. Long-term results are needed to assess outcomes against established techniques.

Practice makes perfect? Institutional coronary artery bypass case volumes and outcomes

OBJECTIVES

Older studies of coronary artery bypass grafting (CABG) institutional case volumes and outcomes reported conflicting results. We explored this association in the rapidly changing contemporary practice of American surgeons using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database.

METHODS

The 2018-2019 isolated primary CABG experience in the STS Adult Cardiac Surgery Database was analysed (241 902 patients; 1014 hospitals; 2718 surgeons). Generalized Estimating Equations were used to estimate coefficients between CABG institutional case volumes and outcomes. The observed-to-expected ratios based on STS risk models were used to assess risk-adjusted operative mortality (OM), mortality/major morbidity (MM) and deep sternal wound infections (DSWI) as a function of institutional case volumes.

RESULTS

The mean (standard deviation) OM, MM and DSWI rates were 2.1% (2.7), 11.1% (9.2) and 0.6% (0.5), respectively. The mean (standard deviation) institutional case volumes per study period was 239 (192); 23% and 9% of institutions performed <100 and >500 cases/study period, respectively. There was a weak negative correlation between expected mortality (R2 -0.0014), OM (R2 -0.0272), MM (R2 -0.1213) and DSWI (R2 -0.003) and institutional case volumes.

CONCLUSIONS

CABG outcomes generally improve with increasing institutional case volumes. Given the large number of CABG cases performed nationally, even the documented weak correlation has the potential to appreciably decrease OM, MM and DSWI if cases are performed at higher volume institutions. Studies focusing on additional hospital and surgeon factors are warranted to further define quality improvement opportunities.

Long-term Outcomes and Anticoagulation in Mitral Valve Surgery-A Report From The Society of Thoracic Surgeons Database

BACKGROUND

Anticoagulation after bioprosthetic mitral valve (MV) replacement (BMVR) and repair (MVrep) is controversial. We explore outcomes among BMVR and MVrep patients in The Society of Thoracic Surgeons Adult Cardiac Surgery Database based on discharge anticoagulation status.

METHODS

BMVR and MVrep patients aged ≥65 years in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were linked to the Centers for Medicare and Medicaid Services claims database. Long-term mortality, ischemic stroke, bleeding, and a composite of the primary end points were compared as a function of anticoagulation. Hazard ratios (HRs) were calculated using multivariable Cox regression.

RESULTS

A total of 26,199 BMVR and MVrep patients were linked to the Centers for Medicare and Medicaid Services database; of these, 44%, 4%, and 52% were discharged on warfarin, non-vitamin K-dependent anticoagulant (NOAC), and no anticoagulation (no-AC; reference), respectively. Warfarin was associated with increased bleeding in the overall study cohort (HR, 1.38; 95% CI 1.26-1.52) and in the BMVR (HR, 1.32; 95% CI, 1.13-1.55) and MVrep subcohorts (HR, 1.42; 95% CI, 1.26-1.60). Warfarin was associated with decreased mortality only among BMVR patients (HR, 0.87; 95% CI, 0.79-0.96). Stroke and the composite outcome did not differ across cohorts with warfarin. NOAC use was associated with increased mortality (HR, 1.33; 95% CI 1.11-1.59), bleeding (HR, 1.37; 95% CI, 1.07-1.74), and the composite outcome (HR, 1.26; 95% CI, 1.08-1.47).

CONCLUSIONS

Anticoagulation was used in fewer than half of mitral valve operations. In MVrep patients, warfarin was associated with increased bleeding and was not protective against stroke or mortality. In BMVR patients, warfarin was associated with a modest survival benefit, increased bleeding, and equivalent stroke risk. NOAC was associated with increased adverse outcomes.

Tailored approach and outcomes of aortic arch reconstruction after acute type A dissection repair

OBJECTIVE

After limited root/ascending with or without hemiarch repair for acute type A aortic dissection (ATAAD), 20% to 30% of patients require distal reintervention, frequently for arch pathology. In this report, we describe an institutional algorithm for arch management after previous limited ATAAD repair and detail operative and long-term outcomes.

METHODS

From August 2005 to April 2021, 71 patients status post previous limited ATAAD repair underwent reoperative arch repair involving zones 1 to 3 for aneurysmal degeneration of residual arch dissection including complete cervical debranching with zone 0/1 thoracic endovascular aortic repair in 6 (8%), open total arch in 13 (18%), type I hybrid arch repair in 23 (32%), and type II/III hybrid arch repair in 29 (41%).

RESULTS

Mean age was 59 ± 12 years; time from index ATAAD repair to reoperation was 4 (interquartile range, 2-9) years. There were 2 (2.8%) in-hospital deaths and 2 (2.8%) postdischarge deaths within 30 days of surgery. Three patients suffered stroke (4.2%) and 2 (2.8%) had acute renal failure requiring dialysis. Overall Kaplan-Meier survival was 78%, 70%, and 58% at 1, 3, and 5 years, respectively. Institutional experience appeared to play a significant role in early and late outcomes, because there have been no operative mortalities in the past 9 years and improved survival of 87% versus 66%, 79% versus 58%, and 79% versus 40% at 1, 3, and 5 years in comparisons of the past 9 years with the previous era (P = .01).

CONCLUSIONS

Aneurysmal degeneration of residual arch dissection after limited ATAAD repair presents a complex reoperative challenge. An algorithmic operative approach tailored to patient anatomy and comorbidities yields excellent early and late outcomes, which continue to improve with increasing institutional experience.

Initial Management Strategy and Long-Term Outcomes in 186 Cases of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare but important nonatherosclerotic cause of acute coronary syndrome. Indications for revascularization and long-term outcomes of SCAD remain areas of active investigation. We report our experience with initial management strategy and long-term outcomes in SCAD. We reviewed all patients treated at our institution from 1996-2021 with a SCAD diagnosis. Demographics, comorbidities, clinical presentations, angiography findings, and management strategies were obtained by chart review. The primary outcome was a composite of cardiac death, recurrent/progressive SCAD, subsequent diagnosis of congestive heart failure, or subsequent/repeat revascularization after the initial management. Unadjusted Kaplan-Meier survival analysis was performed. Of 186 patients with a SCAD diagnosis treated at our institution, 149 (80%) were female. Medical management was the initial treatment in 134 (72.0%) patients, percutaneous coronary intervention (PCI) in 43 (23.1%), and coronary artery bypass grafting in 9 (4.8%). Surgery/PCI intervention was associated with younger age (38.8 vs 47.7 years, P = 0.01), ST elevation myocardial infarction on presentation (67.0% vs 34.0%, P < 0.001), lower ejection fraction (45.0% vs 55.0%, P = 0.002), and left anterior descending coronary artery dissection (75.0% vs 51.0%, P = 0.006). Ten-year freedom from our composite outcome was similar between revascularized patients and those managed with medical therapy (P = 0.36). Median follow-up time was 4.5 years. SCAD in the setting of ST elevation myocardial infarction, left anterior descending coronary artery involvement, or decreased cardiac function suggests greater ischemic insult and was associated with initial percutaneous or surgical revascularization. Despite worse disease on initial presentation, long-term outcomes of patients undergoing revascularization are similar to medically managed patients with SCAD.

Mediators of Improvement in TAVR Outcomes Over Time: Insights From the STS-ACC TVT Registry

BACKGROUND

Over the past decade, there has been substantial improvement in outcomes after transcatheter aortic valve replacement. Many patient and procedural factors have also changed over that time, making it challenging to untangle the drivers of those improvements.

METHODS

Among patients who underwent transcatheter aortic valve replacement from 2012 to 2018 within the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry, we examined the relative contribution of changes in patient factors, device modifications, improving experience/skill, and advances in periprocedural care to the observed improvement in outcomes after transcatheter aortic valve replacement. Mediator clusters included demographics, noncardiovascular comorbidities, cardiovascular comorbidities, device-related factors, and nondevice-related procedural factors. Using logistic regression, we serially adjusted for the mediator clusters to examine the contribution of each to the observed improvement in outcomes over time.

RESULTS

Among 161 196 patients treated with transcatheter aortic valve replacement at 596 sites, outcomes improved steadily from 2012 to 2018, including 30-day mortality (6.7% to 2.4%), 30-day composite adverse events (25.3% to 10.5%), and 1-year mortality (19.9% to 10.1%; all P<0.001). In sequential models, the unadjusted odds ratio for 30-day mortality was 0.82 per year (95% CI, 0.80-0.84), which was progressively attenuated with addition of each covariate cluster. Most of the improvement was explained by device factors and nondevice procedural factors. Results were similar for 30-day composite adverse events, although the observed temporal improvement was not fully explained by measured factors, suggesting improved technical skill as an additional mediator. In contrast to 30-day outcomes, each cluster of patient and procedural factors contributed similarly to the temporal improvement in 1-year mortality, indicating a greater impact of patient factors on longer-term outcomes.

CONCLUSIONS

While US patients undergoing transcatheter aortic valve replacement have become younger, healthier, and lower risk over time, the most important factors contributing to improvements in short-term outcomes relate to advances in device technology and procedural factors, whereas changing patient characteristics had a greater impact on improvement in 1-year outcomes.

Choosing transcatheter aortic valve replacement in porcelain aorta: outcomes versus surgical replacement

OBJECTIVES

Porcelain aorta complicates aortic valve replacement and is an indication for transcatheter approaches. No study has compared surgical and transcatheter valve replacement in the setting of porcelain aorta. We characterize porcelain aorta patients undergoing aortic valve replacement and the association of aortic calcification and outcomes.

METHODS

Patients undergoing aortic valve replacement with porcelain aorta were identified. Aortic calcium volume was determined using 3D computed tomography thresholding techniques. Propensity scoring was performed to assess the effect of surgical versus transcatheter approaches. Risk factors for composite major hospital complications (death, stroke and dialysis) were identified using random forest machine learning.

RESULTS

From January 2006 to January 2015, 164 patients with porcelain aorta underwent aortic valve replacement [105 (64%) surgical replacement, 59 (36%) transcatheter replacement]. Propensity scoring matched 29 pairs (49% of transcatheter patients). Before matching, 5-year survival was 41% [(43% surgical, 35% transcatheter, P(log-rank) = 0.9]. After matching, mortality for surgical versus transcatheter replacement was 3.4% (n = 1) vs 10% (n = 3), stroke 14% (n = 4) vs 3.4% (n = 1) and dialysis 6.9% (n = 2) versus 11% (n = 3). Matched 5-year survival was 40% after surgical replacement and 29% after transcatheter replacement [P(log-rank) = 0.4]. Total aortic calcium volume was greater in transcatheter than surgical patients [18 (8.0) vs 17 (7.7) ml] and was associated with more major hospital complications after either approach.

CONCLUSIONS

Surgical and transcatheter approaches are complementary options for aortic stenosis with porcelain aorta. Surgical valve replacement remains an effective treatment for patients requiring concomitant procedures. Quantifying aortic calcium volume is a helpful risk predictor in all patients with porcelain aorta.

Robotic Esophagectomy Trends and Early Surgical Outcomes: The US Experience

BACKGROUND

Recent esophagectomy trends were evaluated to describe the shift in surgical approach and outcomes using The Society of Thoracic Surgeons General Thoracic Surgery Database.

METHODS

All patients who underwent an esophagectomy with gastric conduit from 2015 to 2019 were identified and analyzed according to original intended approach. After performing volume trend analysis of patients, operative outcomes were evaluated.

RESULTS

Among 10,607 patients, esophagectomy was open in 5763 (54.3%), minimally invasive (MIE) in 3524 (33.2%), and robotic (RAMIE) in 1320 (12.4%). Within 5 years, MIE and RAMIE combined rose to majority approach (open from 58% to 42% of annual volume). While MIE and RAMIE were associated with higher rates of anastomotic leak, loss of conduit, pulmonary embolus, and reoperation, R0 resection and harvested number of lymph nodes exceeded those in open approaches. Operative mortality did not differ by approach (3.21% open vs 2.72% MIE vs 2.50% RAMIE; P = .2329). On multivariable analysis, RAMIE was independently associated with higher rate of anastomotic leak compared to open (adjusted odds ratio 1.53, 95% CI 1.14-2.04), while both MIE and RAMIE had lower mean length of stay. Propensity matching of 1320 pairs found a higher risk of anastomotic leak requiring surgery for RAMIE compared with MIE (adjusted odds ratio 1.39, 95% CI 1.01-1.92).

CONCLUSIONS

In less than a decade, the dominant surgical approach in The Society of Thoracic Surgeons General Thoracic Surgery Database has become minimally invasive (RAMIE and MIE). While anastomotic leak and reoperation, more common in RAMIE, require a technical solution, these complications have not raised operative mortality. Further studies are needed to address long-term results and oncologic outcome.

Perioperative Anemia and Transfusions and Late Mortality in Coronary Artery Bypass Patients

BACKGROUND

Perioperative anemia and transfusions are associated with adverse operative outcomes after coronary artery bypass graft surgery (CABG). Their individual association with long-term outcomes is unclear.

METHODS

Patients aged 65 years and older who had undergone CABG and were in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (n = 504,596) from 2011 to 2018 were linked to Centers for Medicare and Medicaid Service data to assess long-term survival. The association of intraoperative anemia defined by intraoperative nadir hematocrit (nHct) and red blood cell (RBC) transfusions, and their interactions, on long-term mortality were assessed with Kaplan-Meier estimates and multivariable Cox regression. Restricted cubic splines were used to explore the association between nHct as a continuous variable and long-term mortality.

RESULTS

258,398 on-pump CABG STS Adult Cardiac Surgery Database patients surviving the perioperative period were linked to Centers for Medicare and Medicaid Service claims files. Per World Health Organization criteria, 41% had preoperative anemia. Mean intraoperative nHct was 24%; RBC transfusion rate was 43.7%. Univariable analysis associated both RBC transfusion and lower nHct with worse survival. Lower nHct was only marginally associated with risk-adjusted mortality: adjusted hazard ratio (AHR) 1.04 (95% CI, 1.01-1.06) and 1.07 (95% CI, 1.00-1.14) at nHct 20% and at nHct 14%, respectively. RBC transfusion was associated with significantly higher adjusted mortality irrespective of timing of transfusion: AHR intraoperative 1.21 (95% CI, 1.18-1.27); AHR postoperative 1.26 (95% CI, 1.22-1.30); AHR both 1.46 (95% CI, 1.40-1.52) and across all levels of nHct. RBC transfusion was not associated with improved survival at any level of nHct.

CONCLUSIONS

Among Medicare CABG patients, RBC transfusions were associated with increased risk-adjusted late mortality across all levels of nHct whereas intraoperative anemia was only marginally so. Tolerance of lower intraoperative nHct than currently accepted may be preferable to transfusions.

Impact of Transcatheter Mitral Valve Repair Availability on Volume and Outcomes of Surgical Repair

BACKGROUND

The impact of transcatheter edge-to-edge repair (TEER) on national surgical mitral valve repair (MVr) volume and outcomes is unknown.

OBJECTIVES

This study aims to assess the impact of TEER availability on MVr volumes and outcomes for degenerative mitral regurgitation.

METHODS

MVr volume, 30-day and 5-year outcomes, including mortality, heart failure rehospitalization and mitral valve reintervention, were obtained from the Society of Thoracic Surgeons database linked with Medicare administrative claims and were compared within TEER centers before and after the first institutional TEER procedure. A difference-in-difference approach comparing parallel trends in coronary artery bypass grafting outcomes was used to account for temporal improvements in perioperative care.

RESULTS

From July 2011 through December 2018, 13,959 patients underwent MVr at 278 institutions, which became TEER-capable during the study period. There was no significant change in median annualized institutional MVr volume before (32 [IQR: 17-54]) vs after (29 [IQR: 16-54]) the first TEER (P = 0.06). However, higher-risk (Society of Thoracic Surgeons predicted risk of mortality ≥2%) MVr procedures declined over the study period (P < 0.001 for trend). The introduction of TEER was associated with reduced risk-adjusted odds of mortality after MVr at 30 days (adjusted OR: 0.73; 95% CI: 0.54-0.99) and over 5 years (adjusted HR: 0.75; 95% CI: 0.66-0.86). These improvements in 30-day and 5-year mortality were significantly greater than equivalent trends in coronary artery bypass grafting.

CONCLUSIONS

The introduction of TEER has not significantly changed overall MVr case volumes for degenerative mitral regurgitation but is associated with a decrease in higher-risk surgical operations and improved 30-day and 5-year outcomes within institutions adopting the technology.

Selective Sinus Replacement for Aortic Root Aneurysm: Durable Approach in Selected Patients

BACKGROUND

Selective sinus replacement (SSR) allows a tailored repair approach in patients with sinus of Valsalva or asymmetric aortic root aneurysm. SSR avoids the need for coronary reimplantation for nondiseased sinuses and shortens operative time, although potential for late growth of retained sinuses exists. This study describes selection of patients and assesses operative outcomes and late root dimensions after SSR.

METHODS

From 2006 to 2020, 60 patients underwent SSR at a single referral institution. Mixed effect models were used to assess trajectory of postoperative growth of remaining sinuses, adjusting for age of the patient, valve morphology, and baseline root diameter.

RESULTS

Median age of the patients was 57 (interquartile range [IQR], 48-65) years. Twenty-four (40%) had a bicuspid aortic valve. Most patients (n = 55 [92%]) underwent single sinus replacement (n = 46 noncoronary, n = 9 right), whereas 5 (8%) underwent repair of both the right and noncoronary sinuses. Concomitant aortic valve replacement was performed in 15 patients (25%); aortic valve repair with internal ring annuloplasty or cusp plication was performed in 37 (62%). There was no operative death, stroke, renal failure, or respiratory failure. Median preoperative root diameter was 53 mm (IQR, 51-56 mm) vs 42 mm (IQR, 39-45 mm) at median imaging follow-up of 34 (IQR, 13-49) months. Rate of midterm root growth was 0.2 mm/y, and there were no late root reinterventions.

CONCLUSIONS

For patients with sinus of Valsalva or asymmetric root aneurysm, SSR is associated with excellent operative outcomes, and midterm follow-up suggests that the technique is durable. Longer term follow-up is needed to confirm continued stability of the aortic root.

Long-term outcomes of aortic root operations in the United States among Medicare beneficiaries

OBJECTIVE

The best method of aortic root repair in older patients remains unknown given a lack of comparative effectiveness of long-term outcomes data. The objective of this study was to compare long-term outcomes of different surgical approaches for aortic root repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services-linked data.

METHODS

A retrospective cohort study was performed by querying the Society of Thoracic Surgeons Adult Cardiac Surgery Database for patients aged 65 years or more who underwent elective aortic root repair with or without aortic valve replacement. Primary long-term end points were mortality, any stroke, and aortic valve reintervention. Short-term outcomes and long-term survival were compared among each root repair strategy. Additional risk factors for mortality after aortic root repair were assessed with a multivariable Cox proportional hazards model.

RESULTS

A total of 4173 patients aged 65 years or more underwent elective aortic root repair. Patients were stratified by operative strategy: mechanical Bentall, stented bioprosthetic Bentall, stentless bioprosthetic Bentall, or valve-sparing root replacement. Mean follow-up was 5.0 (±4.6) years. Relative to mechanical Bentall, stented bioprosthetic Bentall (adjusted hazard ratio, 0.80; confidence interval, 0.66-0.97) and stentless bioprosthetic Bentall (adjusted hazard ratio, 0.70; confidence interval, 0.59-0.84) were associated with better long-term survival. In addition, stentless bioprosthetic Bentall (adjusted hazard ratio, 0.64; confidence interval, 0.47-0.80) and valve-sparing root replacement (adjusted hazard ratio, 0.51; confidence interval, 0.29-0.90) were associated with lower long-term risk of stroke. Aortic valve reintervention risk was 2-fold higher after valve-sparing root replacement compared with other operative strategies.

CONCLUSIONS

In the Medicare population, there was poorer late survival and greater late stroke risk for patients undergoing mechanical Bentall and a higher rate of reintervention for valve-sparing root replacement. Bioprosthetic Bentall may be the procedure of choice in older patients undergoing aortic root repair, particularly in the era of transcatheter aortic valve replacement.

Comparing Consumer-Directed Hospital Rankings With STS Adult Cardiac Surgery Database Outcomes

BACKGROUND

Public interest in stratifying hospital performance has led to the proliferation of commercial, consumer-oriented hospital rankings. In cardiac surgery, little is known about how these rankings correlate with clinical registry quality ratings.

METHODS

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried for isolated coronary artery bypass grafting or coronary artery bypass grafting/valve patients at hospitals among the top 100 U.S. News & World Report (USNWR) Cardiology & Heart Surgery rankings from 2016 to 2020. Hospitals were grouped into deciles by risk-adjusted observed/expected (O/E) ratios for morbidity and mortality using the STS 2018 risk models. Agreement between STS Adult Cardiac Surgery Database and USNWR ranked deciles was calculated by Bowker symmetry test. The association between each center's annual change in STS O/E ratio and change in USNWR ranking was modeled in repeated measures regression analysis.

RESULTS

Inclusion criteria were met by 524 393 patients from 149 hospitals that ranked in USNWR top 100 at least once during the study period. There was no agreement between USNWR ranking and STS major morbidity and mortality O/E ratio (P > .50 for all years). Analysis of patients undergoing surgery at the 65 hospitals that were consistently ranked in the top 100 during the study period demonstrated no association between annual change in hospital ranking and change in O/E ratio (P all > .3).

CONCLUSIONS

There was no agreement between annual USNWR hospital ranking and corresponding risk-adjusted STS morbidity or mortality. Furthermore, annual changes in USNWR rankings could not be accounted for using clinical outcomes. These findings suggest that factors unrelated to key surgical outcomes may be driving consumer-directed rankings.

A Randomized Trial of Mesenchymal Stromal Cells for Moderate to Severe Acute Respiratory Distress Syndrome from COVID-19

Rationale: There are limited therapeutic options for patients with coronavirus disease (COVID-19)-related acute respiratory distress syndrome with inflammation-mediated lung injury. Mesenchymal stromal cells offer promise as immunomodulatory agents. Objectives: Evaluation of efficacy and safety of allogeneic mesenchymal cells in mechanically-ventilated patients with moderate or severe COVID-19-induced respiratory failure. Methods: Patients were randomized to two infusions of 2 million cells/kg or sham infusions, in addition to the standard of care. We hypothesized that cell therapy would be superior to sham control for the primary endpoint of 30-day mortality. The key secondary endpoint was ventilator-free survival within 60 days, accounting for deaths and withdrawals in a ranked analysis. Measurements and Main Results: At the third interim analysis, the data and safety monitoring board recommended that the trial halt enrollment as the prespecified mortality reduction from 40% to 23% was unlikely to be achieved (n = 222 out of planned 300). Thirty-day mortality was 37.5% (42/112) in cell recipients versus 42.7% (47/110) in control patients (relative risk [RR], 0.88; 95% confidence interval, 0.64-1.21; P = 0.43). There were no significant differences in days alive off ventilation within 60 days (median rank, 117.3 [interquartile range, 60.0-169.5] in cell patients and 102.0 [interquartile range, 54.0-162.5] in control subjects; higher is better). Resolution or improvement of acute respiratory distress syndrome at 30 days was observed in 51/104 (49.0%) cell recipients and 46/106 (43.4%) control patients (odds ratio, 1.36; 95% confidence interval, 0.57-3.21). There were no infusion-related toxicities and overall serious adverse events over 30 days were similar. Conclusions: Mesenchymal cells, while safe, did not improve 30-day survival or 60-day ventilator-free days in patients with moderate and/or severe COVID-19-related acute respiratory distress syndrome.

Initial Thoracic Endovascular Aortic Repair vs Medical Therapy for Acute Uncomplicated Type B Aortic Dissection

Importance

Thoracic endovascular aortic repair (TEVAR) has increasingly been used for uncomplicated type B aortic dissection (uTBAD) despite limited supporting data.

Objective

To assess whether initial TEVAR following uTBAD is associated with reduced mortality or morbidity compared with medical therapy alone.

Design, Setting, and Participants

This cohort study included Centers for Medicare & Medicaid Services inpatient claims data for adults aged 65 years or older with index admissions for acute uTBAD from January 1, 2011, to December 31, 2018, with follow-up available through December 31, 2019.

Exposures

Initial TEVAR was defined as TEVAR within 30 days of admission for acute uTBAD.

Main Outcomes and Measures

Outcomes included all-cause mortality, cardiovascular hospitalizations, aorta-related and repeated aorta-related hospitalizations, and aortic interventions associated with initial TEVAR vs medical therapy. Propensity score inverse probability weighting was used.

Results

Of 7105 patients with eligible index admissions for acute uTBAD, 1140 (16.0%) underwent initial TEVAR (623 [54.6%] female; median age, 74 years [IQR, 68-80 years]) and 5965 (84.0%) did not undergo TEVAR (3344 [56.1%] female; median age, 76 years [IQR, 69-83 years]). Receipt of TEVAR was associated with region (vs South; Midwest: adjusted odds ratio [aOR], 0.66 [95% CI, 0.53-0.81]; P < .001; Northeast: aOR, 0.63 [95% CI, 0.50-0.79]; P < .001), Medicaid dual eligibility (aOR, 0.76; 95% CI, 0.63-0.91; P = .003), hypertension (aOR, 1.26; 95% CI, 1.03-1.54; P = .03), peripheral vascular disease (aOR, 1.24; 95% CI, 1.02-1.49; P = .03), and year of admission (2012, 2013, 2014, and 2015 were associated with greater odds of TEVAR compared with 2011). After inverse probability weighting, mortality was similar for the 2 strategies up to 5 years (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06), as were aorta-related hospitalizations (HR, 1.12; 95% CI, 0.99-1.27), aortic interventions (HR, 1.01; 95% CI, 0.84-1.20), and cardiovascular hospitalizations (HR, 1.05; 95% CI, 0.93-1.20). In a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality over a period of 1 year (adjusted HR [aHR], 0.86; 95% CI, 0.75-0.99; P = .03), 2 years (aHR, 0.85; 95% CI, 0.75-0.96; P = .008), and 5 years (aHR, 0.87; 95% CI, 0.80-0.96; P = .004).

Conclusions and Relevance

In this study, 16.0% of patients underwent initial TEVAR within 30 days of uTBAD, and receipt of initial TEVAR was associated with hypertension, peripheral vascular disease, region, Medicaid dual eligibility, and year of admission. Initial TEVAR was not associated with improved mortality or reduced hospitalizations or aortic interventions over a period of 5 years, but in a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality. These findings, along with cost-effectiveness and quality of life, should be assessed in a prospective trial in the US population.

Association Between Device Type and Type IIIb Endoleaks Following Thoracic Endovascular Aortic Repair

OBJECTIVE

Endoleaks following thoracic endovascular aortic repair (TEVAR) can lead to the need for re-intervention and aortic rupture. Given the recent recall of a specific thoracic stent graft type due to concerns about type IIIb endoleak (T3bE), in which blood leaks through the stent graft fabric, the aim was to characterise patterns of T3bEs among available TEVAR devices.

METHODS

Reports related to thoracic stent grafts in the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database between 2010 and 2020 were reviewed. Proportional reporting ratios (PRRs) and chi squared tests were used to assess for the presence of a signal of association between device type and T3bE. A PRR > 2 and chi squared value > 4 with three or more reports overall constituted a signal of association. The institutional database of patients undergoing TEVAR for thoracic aneurysms since 2002 was also queried for T3bE.

RESULTS

There were 7 328 MAUDE reports available for analysis. When analysing T3bEs in the MAUDE database, the lowest PRR was 0.36 (95% confidence interval [CI] 0 - 1.03 in Gore CTAG, nine T3bE among 1 328 reports) and the highest was 2.07 (95% CI 1.72 - 2.42 in Medtronic Valiant, 64 T3bE among 2 520 reports). The T3bE chi squared value for Medtronic Valiant was 17.3. The relationship between Medtronic Valiant and T3bE was ascertainable by MAUDE data as early as 2013. Among 542 TEVARs for an aneurysm indication at Duke University Hospital since 2002, there were eight T3bEs - all in devices with sutured on graft material.

CONCLUSION

The Medtronic Valiant device met criteria for association with type IIIb endoleaks in the FDA's MAUDE database and met those criteria as early as 2013. A possible relationship between woven graft fabric and T3bEs is supported by the observation that all types of T3bE that occurred among a large number of TEVARs at the institution followed placement of grafts with sutured on woven fabric.

Efficacy and Safety of Ensovibep for Adults Hospitalized With COVID-19 : A Randomized Controlled Trial

BACKGROUND

Ensovibep (MP0420) is a designed ankyrin repeat protein, a novel class of engineered proteins, under investigation as a treatment of SARS-CoV-2 infection.

OBJECTIVE

To investigate if ensovibep, in addition to remdesivir and other standard care, improves clinical outcomes among patients hospitalized with COVID-19 compared with standard care alone.

DESIGN

Double-blind, randomized, placebo-controlled, clinical trial. (ClinicalTrials.gov: NCT04501978).

SETTING

Multinational, multicenter trial.

PARTICIPANTS

Adults hospitalized with COVID-19.

INTERVENTION

Intravenous ensovibep, 600 mg, or placebo.

MEASUREMENTS

Ensovibep was assessed for early futility on the basis of pulmonary ordinal scores at day 5. The primary outcome was time to sustained recovery through day 90, defined as 14 consecutive days at home or place of usual residence after hospital discharge. A composite safety outcome that included death, serious adverse events, end-organ disease, and serious infections was assessed through day 90.

RESULTS

An independent data and safety monitoring board recommended that enrollment be halted for early futility after 485 patients were randomly assigned and received an infusion of ensovibep (n = 247) or placebo (n = 238). The odds ratio (OR) for a more favorable pulmonary outcome in the ensovibep (vs. placebo) group at day 5 was 0.93 (95% CI, 0.67 to 1.30; P = 0.68; OR > 1 would favor ensovibep). The 90-day cumulative incidence of sustained recovery was 82% for ensovibep and 80% for placebo (subhazard ratio [sHR], 1.06 [CI, 0.88 to 1.28]; sHR > 1 would favor ensovibep). The primary composite safety outcome at day 90 occurred in 78 ensovibep participants (32%) and 70 placebo participants (29%) (HR, 1.07 [CI, 0.77 to 1.47]; HR < 1 would favor ensovibep).

LIMITATION

The trial was prematurely stopped because of futility, limiting power for the primary outcome.

CONCLUSION

Compared with placebo, ensovibep did not improve clinical outcomes for hospitalized participants with COVID-19 receiving standard care, including remdesivir; no safety concerns were identified.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Open arch surgery in the redo setting: contemporary outcomes

BACKGROUND

Aortic arch reconstruction after prior cardiac surgery is technically complex, especially after proximal aortic surgery. While multiple surgical adaptations in the redo setting have been described, traditional open reconstruction remains the most common approach with significant variability in outcomes in prior reports. This study describes institutional adaptations to surgical technique and perioperative care and assesses operative and long-term outcomes after redo-aortic arch repair in the modern era.

METHODS

Patients undergoing hemi- or total arch reconstruction after prior cardiac surgery (2005-2022) were identified from a prospectively maintained institutional database. Strategic adaptations in approach over the study interval included a shift towards Type II hybrid arch repair for patients with "mega-aorta," redo-cannulation of the axillary artery when necessary, and adoption of transfusion and early extubation protocols. Outcomes of interest included 30-day/in-hospital adverse events and actuarial long-term overall and aorta-specific survival.

RESULTS

The study cohort included 214 patients undergoing hemi-arch (N.=154, 72%) or total arch (N.=60, 28%) after prior cardiac surgery (50% prior proximal aortic surgery). Surgical indications included degenerative aneurysm (47%, N.=101), residual arch dissection after prior type A repair (29%, N.=61), acute or chronic type A dissection (18%, N.=39) or other (6%, N.=13). 30-day/in-hospital mortality was 6% (5% hemi-arch; 10% total arch) and stroke was 3% (3% hemi-arch; 2% total arch). At median follow-up of 56 months, overall 5- and 10-year survival was 76% and 58% (hemi-arch: 81%, 62%; total arch: 63%, 43%); aorta-specific survival was 91% and 90% (hemi-arch: 96%, 94%; total arch: 79%, 79%).

CONCLUSIONS

In this modern single-institution series, a systematic approach to redo-arch repair yields excellent operative outcomes and late aorta-specific survival. Reduced late overall survival reflects the comorbidity burden of this population. Open reconstruction continues to play an important role in reoperative arch repair in the modern era.

Anticoagulation in new-onset postoperative atrial fibrillation: An analysis from the Society of Thoracic Surgeons Adult Cardiac Surgery Database

Background

New-onset postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and is associated with increased long-term stroke and mortality. Anticoagulation has been suggested as a potential therapy, but data on safety and efficacy are scant.

Objectives

To determine the association between anticoagulation for POAF and long-term outcomes.

Methods

Adult patients with POAF after isolated coronary artery bypass surgery (CABG) were identified through the Society of Thoracic Surgeons Adult Cardiac Surgery Database and linked to the Medicare Database. Propensity-matched analyses were performed for all-cause mortality, stroke, myocardial infarction, and major bleeding for patients discharged with or without anticoagulation. Interaction between anticoagulation and CHA₂DS₂-VASc score was also assessed.

Results

Of 38,936 patients, 9861 (25%) were discharged on oral anticoagulation. After propensity score matching, discharge anticoagulation was associated with increased mortality (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.06–1.26). There was no difference in ischemic stroke between groups (HR 0.97, 95% CI 0.82–1.15), but there was significantly higher bleeding (HR 1.60, 95% CI 1.38–1.85) among those discharged on anticoagulation. Myocardial infarction was lower in the first 30 days for those discharged on anticoagulation, but this effect decreased over time. The incidence of all complications was higher for patients with CHA₂DS₂-VASc scores ≥5 compared to patients with scores of 2–4. Anticoagulation did not appear to benefit either subgroup.

Conclusion

Anticoagulation is associated with increased mortality after new-onset POAF following CABG. There was no reduction in ischemic stroke among those discharged on anticoagulation regardless of CHA₂DS₂-VASc score.

Targeted Delivery for Cardiac Regeneration: Comparison of Intra-coronary Infusion and Intra-myocardial Injection in Porcine Hearts

BACKGROUND

The optimal delivery route to enhance effectiveness of regenerative therapeutics to the human heart is poorly understood. Direct intra-myocardial (IM) injection is the gold standard, however, it is relatively invasive. We thus compared targeted IM against less invasive, catheter-based intra-coronary (IC) delivery to porcine myocardium for the acute retention of nanoparticles using cardiac magnetic resonance (CMR) imaging and viral vector transduction using qPCR.

METHODS

Ferumoxytol iron oxide (IO) nanoparticles (5 ml) were administered to Yorkshire swine (n = 13) by: (1) IM via thoracotomy, (2) catheter-based IC balloon-occlusion (BO) with infusion into the distal left anterior descending (LAD) coronary artery, (3) IC perforated side-wall (SW) infusion into the LAD, or (4) non-selective IC via left main (LM) coronary artery infusion. Hearts were harvested and imaged using at 3T whole-body MRI scanner. In separate Yorkshire swine (n = 13), an adeno-associated virus (AAV) vector was similarly delivered, tissue harvested 4-6 weeks later, and viral DNA quantified from predefined areas at risk (apical LV/RV) vs. not at risk in a potential mid-LAD infarct model. Results were analyzed using pairwise Student's t-test.

RESULTS

IM delivery yielded the highest IO retention (16.0 ± 4.6% of left ventricular volume). Of the IC approaches, BO showed the highest IO retention (8.7 ± 2.2% vs. SW = 5.5 ± 4.9% and LM = 0%) and yielded consistent uptake in the porcine distal LAD territory, including the apical septum, LV, and RV. IM delivery was limited to the apex and anterior wall, without septal retention. For the AAV delivery, the BO was most efficient in the at risk territory (Risk: BO = 6.0 × 10-9, IM = 1.4 × 10-9, LM = 3.2 × 10-10 viral copies per μg genomic DNA) while all delivery routes were comparable in the non-risk territory (BO = 1.7 × 10-9, IM = 8.9 × 10-10, LM = 1.2 × 10-9).

CONCLUSIONS

Direct IM injection has the highest local retention, while IC delivery with balloon occlusion and distal infusion is the most effective IC delivery technique to target therapeutics to a heart territory most in risk from an infarct.

Stent Graft-Induced Aortic Wall Injury (SAWI) - Incidence, Risk Factors, and Outcomes

BACKGROUND

Stent graft-induced new entry (SINE) has been described in thoracic endovascular aortic repair (TEVAR) for aortic dissection. The incidence of stent graft-induced aortic wall injury (SAWI) related to iatrogenic injury in non-dissections is incompletely described. We describe incidence, risk factors, and outcomes of SAWI.

METHODS

All post-TEVAR CT angiograms (1/2005-12/2018) were reviewed for radiographic evidence of SAWI. Endograft-induced aortic dissections were likewise considered SAWI. Patient characteristics, time to SAWI, and need for re-intervention were noted. Cox proportional hazards modeling was used to identify risk factors for SAWI.

RESULTS

Within the study cohort (n=430), 38 (9%) patients developed SAWI during a median follow-up of 2.3 years (IQR 4.8 years). 42% (n=16) of SAWI were proximal, 53% (n=20) distal and 5% (n=2) both proximal and distal. Nine (23%) were distal intimal flap injuries in dissection cases, thus sub-classifying them as SINE. 29% (n=11) of SAWI required re-intervention. Of these, 45% (n=5) were open and 55% (n=6) endovascular. TEVAR for acute dissection had a higher incidence of SAWI development (HR 4.6, 95% CI: [2.4, 9.0]; p<0.001) as compared to other indications. Use of devices with proximal bare springs or barbs was also associated with increased SAWI incidence (HR 5.3, 95% CI: [2.6, 11.0]; p<0.001).

CONCLUSIONS

The rate of SAWI following TEVAR is low (9%), but nearly one-third will require re-intervention. TEVAR in the setting of acute dissection and use of devices with proximal bare springs or barbs were associated with an increased incidence of SAWI.

Patient-Reported Versus Physician-Estimated Symptoms Before and After TAVR

AIMS

In contrast to patient-reported health status measures (such as the Kansas City Cardiomyopathy Questionnaire [KCCQ]), New York Heart Association (NYHA) Class is based on a physician's assessment of heart failure symptoms and functional limitations on behalf of the patient. We sought to determine the concordance and predictors of physician under- and overestimation of symptoms prior to and after transcatheter aortic valve replacement (TAVR).

METHODS AND RESULTS

The analytic cohort included 172,667 patients within the STS/ACC TVT Registry who underwent transfemoral TAVR. At baseline, physicians underestimated patients' symptoms in 47.4%, correctly assessed symptoms in 26.6%, and overestimated symptoms in 26.0%. At 30 days after TAVR, these proportions were 22.8%, 50.3%, and 26.9%, respectively. Using nominal logistic regression with random intercepts to account for within hospital clustering, we found that physicians were more likely to incorrectly estimate patients' symptoms when patients were older, women, had a prior stroke, had severe lung disease, had atrial fibrillation, or were more obese. There was marked variability in the rates of underestimation, correct estimation, and overestimation across the 641 sites.

CONCLUSION

Among patients undergoing treatment for severe aortic stenosis, physicians estimate patients' symptoms and functional status poorly both prior to and after TAVR, with different patterns. These findings emphasize the need to collect patient-reported health status to more reliably assess the benefits of TAVR in routine clinical practice.

Does deeper hypothermia reduce the risk of acute kidney injury after circulatory arrest for aortic arch surgery?

OBJECTIVES

The impact of hypothermic circulatory arrest (HCA) temperature on postoperative acute kidney injury (AKI) has not been evaluated. This study examined the association between circulatory arrest temperatures and AKI in patients undergoing proximal aortic surgery with HCA.

METHODS

A total of 759 consecutive patients who underwent proximal aortic surgery (ascending ± valve ± root) including arch replacement requiring HCA between July 2005 and December 2016 were identified from a prospectively maintained institutional aortic surgery database. The primary outcome was AKI as defined by Risk, Injury, Failure, Loss, End Stage Renal Disease (ESRD) criteria. The association between minimum nasopharyngeal (NP) and bladder temperatures during HCA and postoperative AKI was assessed, adjusting for patient-level factors using multivariable logistic regression.

RESULTS

A total of 85% (n = 645) of patients underwent deep hypothermia (14.1-20.0°C), 11% (n = 83) low-moderate hypothermia (20.1-24.0°C) and 4% (n = 31) high-moderate hypothermia (24.1-28.0°C) as classified by NP temperature. When analysed by bladder temperature, 59% (n = 447) underwent deep hypothermia, 22% (n = 170) low-moderate, 16% (n = 118) high-moderate and 3% mild (n = 24) (28.1-34.0°C) hypothermia. The median systemic circulatory arrest time was 17 min. The incidence of AKI did not differ between hypothermia groups, whether analysed using minimum NP or bladder temperature. In the multivariable analysis, the association between degree of hypothermia and AKI remained non-significant whether analysed as a categorical variable (hypothermia group) or as a continuous variable (minimum NP or bladder temperature) (all P > 0.05).

CONCLUSIONS

In patients undergoing proximal aortic surgery including arch replacement requiring HCA, degree of systemic hypothermia was not associated with the risk of AKI. These data suggest that moderate hypothermia does not confer increased risk of AKI for patients requiring circulatory arrest, although additional prospective data are needed.

Aortic valve repair with a newly approved geometric annuloplasty ring in patients undergoing proximal aortic repair: early results from a single-centre experience

OBJECTIVES

Aortic insufficiency (AI) is common in patients with proximal aortic disease, but limited options exist to facilitate aortic valve repair (AVr) in this population. This study reports 'real-world' early results of AVr using newly FDA-approved trileaflet and bicuspid geometric annuloplasty rings for patients with AI undergoing proximal aortic repair (PAR) in a single referral centre.

METHODS

All patients undergoing AVr with a rigid internal geometric annuloplasty ring (n = 47) in conjunction with PAR (ascending +/- root +/- arch) were included. Thirty-six patients underwent AVr with a trileaflet ring, and 11 patients underwent AVr with a bicuspid ring. The rings were implanted in the subannular position, and concomitant leaflet repair was performed if required for cusp prolapse identified after ring placement.

RESULTS

The median age was 58 years [interquartile range (IQR) 46-70]. PAR included supracoronary ascending replacement in 26 (55%) patients and remodelling valve-sparing root replacement with selective sinus replacement in 20 (42%) patients. Arch replacement was performed in 38 (81%) patients, including hemi-arch in 34 patients and total arch in 4 patients. There was no 30-day/in-hospital mortality. Preoperative AI was 3-4+ in 37 (79%) patients. Forty-one (87%) patients had zero-trace AI on post-repair transoesophageal echocardiography, and 6 patients had 1+ AI. The median early post-repair mean gradient was 13 mmHg (IQR 5-20). Follow-up imaging was available in 32 (68%) patients at a median of 11 months (IQR 10-13) postsurgery. AI was ≤1+ in 97% of patients with 2+ AI in 1 patient. All patients were alive and free from aortic valve reintervention at last follow-up.

CONCLUSIONS

Early results with geometric rigid internal ring annuloplasty for AVr in patients undergoing PAR appear promising and allow a standardized approach to repair with annular diameter reduction and cusp plication when needed. Longer-term follow-up will be required to ensure the durability of the procedure.

Long-term outcomes of aortic root replacement for endocarditis

BACKGROUND

Infective endocarditis (IE) involving the aortic valve and root is associated with high risk requiring thoughtful surgical decision-making. The impact of valve and conduit choices and patient factors on long-term outcomes in this patient population is poorly documented.

METHODS

From January 1976 to December 2013, 485 patients underwent aortic root and valve replacement at a single institution. Cox's proportional hazard model identified predictors of long-term survival and cumulative incidence functions were compared to assess need for reoperation with death as a competing risk.

RESULTS

Median age at time of operation was 56.6 years (interquartile range: 23.1) with the indication for operation being endocarditis in 14.6% (n = 71). Stentless root replacement was used in 70% IE versus 34% non-IE (p < .001). Endocarditis at time of root replacement did not have a significant impact on survival through 15 years (IE: 37.3% vs. non-IE: 42.5%; log-rank; p = .13). After multivariable adjustment, survival was similar between patients with and without endocarditis (hazard ratio: 1.1; 95% confidence interval: [0.77, 1.62]; p = .57). Freedom from reoperation at 15 years did not vary significantly by endocarditis status (IE: 95.9% vs. non-IE: 73.6%; p = .07). Among endocarditis patients, freedom from reoperation at 10 years was similar between homograft and stentless bioprosthetic conduits (95.3% vs. 88.5%; log-rank; K-sample; p = .46).

CONCLUSIONS

In a sample with frequent use of stentless prostheses, aortic root replacement for infective endocarditis had acceptable risk and long-term survival similar to root replacement for other indications. In the setting of endocarditis, root replacement with homograft or stentless bioprosthetic root has excellent durability through 15 years.

Borrowing from Adult Cardiac Surgeons-Bringing Congenital Heart Surgery Up to Speed in the Minimally Invasive Era

The majority of congenital and adult cardiac surgery is performed through a median sternotomy. For surgeons, this incision provides excellent exposure; however, for patients, a median sternotomy confers a poorer cosmetic outcome and the possibility of postoperative respiratory dysfunction, chronic pain, and deep sternal wound infections. Despite the advances in adult cardiac surgery, the use of minimally invasive techniques in pediatric patients is largely limited to small case series and less complex repairs. In this article, we review the risks, benefits, and limitations of the minimally invasive congenital cardiac approaches being performed today. The interest in these approaches continues to grow as more data supporting reduced morbidity, decreased length of stay, and faster recovery are published. In the future, as the technology and surgical familiarity improve, these alternative approaches will become more common, and may someday become the standard of care.

Left Anterior Mini-Incision for Pulmonary Valve Replacement Following Tetralogy of Fallot Repair

Pulmonary insufficiency is a known complication following Tetralogy of Fallot repair. With over 90% of patients now surviving to adulthood, surgeons are once again faced with the question of when, and more importantly, how to reintervene. We developed a novel approach to pulmonary valve replacement in this population through a 5-cm left anterior mini-incision. The incision is optimized for exposing and operating on the right ventricular outflow tract and the main pulmonary artery in patients with a history of median sternotomy. Early outcomes are reassuring, and we believe our approach is a safe and reliable alternative to median sternotomy within this patient population, with the ability to quickly convert intraoperatively when needed.

Left Anterior Mini-Incision for Pulmonary Valve Replacement in a 12-Year-Old

A 12-year-old, 32 kg male with history of Tetralogy of Fallot status post repair at 8 days of life presented with progressive pulmonary insufficiency and left pulmonary artery stenosis. Surgical options were discussed, and the patient and his family elected to pursue minimally invasive pulmonary valve replacement with left pulmonary artery augmentation through a 5-cm left anterior mini-incision. The procedure was performed without complication, and he was discharged on postoperative day 3. At the time of his last follow-up, the patient was recovering well without evidence of pulmonary stenosis or insufficiency.

Outcomes after aortic graft-to-graft anastomosis with an automated circular stapler: A novel approach

OBJECTIVE

Patients with complex aortic disease often require multistaged repairs with numerous anastomoses. Manual suturing can be time consuming. To reduce ischemic time, a circular stapling device has been used to facilitate prosthetic graft-to-graft anastomoses. Objectives are to describe this technique and assess outcomes.

METHODS

From February 2009 to May 2014, 44 patients underwent complex aortic repair with a circular end-to-end anastomosis (EEA) stapler at Cleveland Clinic. All patients had extensive aneurysms: 17 after ascending dissection repair, 10 chronic type B dissections, and 17 degenerative aneurysms. Stapler was used during total arch repair as an end-to-side anastomosis (n = 36; including first stage elephant trunk [ET] in 32, frozen ET in 3) and an end-to-end anastomosis during redo thoracoabdominal repair (n = 11). Three patients had the stapler used during both stages of repair. Patients underwent early and annual follow-ups with computed tomography analysis.

RESULTS

There were no bleeds, ruptures, or leaks at the stapled site, but 2 patients died. Complications included 7 reoperations not related to the site of stapled anastomosis and 6 tracheostomies, but there was no paralysis or renal failure. Mean circulatory arrest time was 16 ± 5 minutes. Mean follow-up was 26 ± 17 months and consisted of imaging before discharge, at 3 to 6 months, and at 1 year. Planned reinterventions included 21 second-stage ET completion: Endovascular (n = 18) and open (n = 3). There were 4 late deaths.

CONCLUSIONS

Use of an end-to-end anastomotic automated circular stapler is safe, effective, and durable in performing graft-to-graft anastomoses during complex thoracic aortic surgery. Further evaluation and refinement of this technique are warranted.