Contemporary experience with the Commando procedure for anterior mitral anular calcification

Objective

Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements.

Methods

From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs).

Results

Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47).

Conclusions

The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

Neighborhood Socioeconomic Status and Readmission in Acute Type A Aortic Dissection Repair

INTRODUCTION

We examined the association of socioeconomic status as defined by median household income quartile (MHIQ) with mortality and readmission patterns following open repair of acute type A aortic dissection (ATAAD) in a nationally representative registry.

METHODS

Adults who underwent open repair of ATAAD were selected using the US Nationwide Readmissions Database and stratified by MHIQ. Patients were selected based on diagnostic and procedural codes. The primary endpoint was 30-d readmission.

RESULTS

Between 2016 and 2019, 10,288 individuals (65% male) underwent open repair for ATAAD. Individuals in the lowest income quartile were younger (median: 60 versus 64, P < 0.05) but had greater Elixhauser comorbidity burden (5.9 versus 5.7, P < 0.05). Across all groups, in-hospital mortality was approximately 15% (P = 0.35). On multivariable analysis adjusting for baseline comorbidity burden, low socioeconomic status was associated with increased readmission at 90 d, but not at 30 d. Concomitant renal disease (odds ratio [OR], 1.68; P < 0.001), pulmonary disease (OR, 1.26; P < 0.001), liver failure (OR 1.2, P = 0.04), and heart failure (OR, 1.17; P < 0.001) were all associated with readmission at 90 d. The primary indication for readmission was most commonly cardiac (33%), infectious (16.5%), and respiratory (9%).

CONCLUSIONS

In patients who undergo surgery for ATAAD, lower MHIQ was associated with higher odds of readmission following open repair. While early readmission for individuals living in the lowest income communities is likely attributable to greater baseline comorbidity burden, we observed that 90-d readmission rates are associated with lower MHIQ regardless of comorbidity burden. Further investigation is required to determine which patient-level and system-level interventions are needed to reduce readmissions in the immediate postoperative period for resource poor areas.

Well-functioning bicuspid aortic valves should be preserved during aortic replacement for the ascending aortopathy phenotype

OBJECTIVES

Consensus has not been reached on whether or not to replace or preserve a well-functioning bicuspid aortic valve (BAV) in patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. We characterize morphology, evaluate progression of aortic regurgitation or aortic stenosis, and investigate the need for aortic valve replacement in patients whose well-functioning BAV was preserved during ascending aortic replacement ≥10 years prior.

METHODS

From January 1991 to August 2011, 191 patients with a well-functioning BAV underwent supracoronary aortic replacement (113 valves were minimally repaired). Aortic morphology was evaluated, aortic regurgitation grade and transvalvular aortic gradient modeled parametrically, and survival assessed by the Kaplan-Meier method. Median follow-up was 10 years.

RESULTS

Mean aortic diameter was 2.9 ± 0.53 cm at the annulus and 4.2 ± 0.55 cm at the sinuses. Mean maximum ascending diameter was 5.1 ± 0.49 cm. All patients exhibited a cusp-fusion BAV phenotype. Fifteen-year progression to severe aortic regurgitation was 3.2%. Mean aortic valve gradient began to rise 5 years postoperatively to 27 mm Hg by 14 years. Freedom from aortic valve replacement at 1, 5, 10, and 15 years was 100%, 95%, 83%, and 63%, respectively. Minimal valve repair was not associated with late aortic valve replacement. Fifteen-year survival was 74%.

CONCLUSIONS

Preserving a well-functioning BAV should be considered in carefully selected patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. The valves remain durable in the long term, with slow progression of regurgitation or stenosis, and low probability of aortic valve replacement through 10 years.

Age-Stratified Surgical Aortic Valve Replacement for Aortic Stenosis

BACKGROUND

The management of aortic stenosis has evolved to stratification by age as reflected in recent societal guidelines. We evaluated age-stratified surgical aortic valve replacement (SAVR) trends and outcomes in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) from The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

METHODS

This cohort included adults (≥18 years) undergoing SAVR for severe aortic stenosis between July 2011 and December 2022. Comparisons were stratified by age (<65 years, 65-79 years, ≥80 years) and BAV or TAV status. Primary end points included operative mortality, composite morbidity and mortality, and permanent stroke. Observed to expected ratios by The Society of Thoracic Surgeons predicted risk of mortality were calculated.

RESULTS

In total, 200,849 SAVR patients (55,326 BAV [27.5%], 145,526 TAV [72.5%]) from 1238 participating hospitals met study criteria. Annual SAVR volumes decreased by 45% (19,560 to 10,851) during the study period. The decrease was greatest (96%) for patients ≥80 years of age (4914 to 207). The relative prevalence of BAV was greater in younger patients (<65 years, 69,068 [49.5% BAV]; 65-79 years, 104,382 [19.1% BAV]; ≥80 years, 27,399 [4.5% BAV]). The observed mortality in <80-year-old BAV patients (<65 years, 1.08; 65-79 years, 1.21; ≥80 years, 3.68) was better than the expected mortality rate (<65 years, 1.22; 65-79 years, 1.54; ≥80 years, 3.14).

CONCLUSIONS

SAVR volume in the transcatheter era has decreased substantially, particularly for patients ≥80 years old and for those with TAV. Younger patients with BAV have better than expected outcomes, which should be carefully considered during shared decision-making in the treatment of aortic stenosis. SAVR should remain the preferred therapy in this population.

Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair

OBJECTIVE

The study objective was to determine the effect of sinutubular junction stabilization on long-term outcomes of bicuspid aortic valve repair.

METHODS

From January 1998 to January 2020, 419 patients underwent bicuspid aortic valve repair with ascending aorta replacement and 421 without (bicuspid aortic valve repair alone). Propensity score matching (97 pairs) was used to compare outcomes.

RESULTS

Before matching, prevalence of severe aortic regurgitation at 10 years was 5.4% after bicuspid aortic valve repair + ascending aorta replacement and 10% after bicuspid aortic valve repair alone; aortic valve gradient was 20 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 19 mm Hg after bicuspid aortic valve repair alone. Ten-year freedom from reoperation overall was 79% after bicuspid aortic valve repair + ascending aorta replacement and 75% after bicuspid aortic valve repair alone; freedom from late aortic regurgitation was 93% after bicuspid aortic valve repair + ascending aorta replacement and 92% after bicuspid aortic valve repair alone; and freedom from aortic stenosis was 87% after bicuspid aortic valve repair + ascending aorta replacement and 93% after bicuspid aortic valve repair alone. Ten-year survival was 95% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone. After matching, prevalence of severe aortic regurgitation at 10 years was 11% after bicuspid aortic valve repair + ascending aorta replacement and 9.1% after bicuspid aortic valve repair alone (P = .33); aortic valve gradient was 16 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 25 mm Hg after bicuspid aortic valve repair alone (P < .0001). Ten-year freedom from reoperation was 85% after bicuspid aortic valve repair + ascending aorta replacement and 72% after bicuspid aortic valve repair alone (P = .08) overall. Ten-year freedom from reoperation for late aortic regurgitation was 88% after bicuspid aortic valve repair + ascending aorta replacement and 86% after bicuspid aortic valve repair alone (P = .65). Freedom from aortic stenosis was 97% after bicuspid aortic valve repair + ascending aorta replacement and 91% after bicuspid aortic valve repair alone (P = .03). Ten-year survival was 96% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone (P = .16).

CONCLUSIONS

Bicuspid aortic valve repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Bicuspid aortic valve repair + ascending aorta replacement has a minimal effect on long-term repair durability. Sinutubular junction stabilization should not be performed for the sole purpose of long-term repair durability.

The decreasing risk of reoperative aortic valve replacement: Implications for valve choice and transcatheter therapy

OBJECTIVE

Increasing use of bioprostheses for surgical aortic valve replacement (SAVR) in younger patients, together with wider use of transcatheter aortic valve replacement, necessitates understanding risks associated with surgical valve reintervention. Therefore, we sought to identify risks of reoperative SAVR compared with those of primary isolated SAVR.

METHODS

From January 1980 to July 2017, 7037 patients underwent nonemergency isolated SAVR, with 753 reoperations and 6284 primary isolated operations. These 2 groups were propensity score-matched on 46 preoperative variables, yielding 581 patient pairs for comparing outcomes.

RESULTS

Among propensity score-matched patients, aortic clamp time (median 63 vs 52 minutes; P < .0001), cardiopulmonary bypass time (median 88 vs 67 minutes; P < .0001), and postoperative stay (median 7.1 vs 6.9 days; P = .003) were longer for reoperative SAVR than primary isolated SAVR. Hospital mortality after reoperative SAVR decreased from 3.4% in 1985 to 1.3% in 2011, similar to that of primary isolated SAVR. Occurrence of stroke, deep sternal wound infection, and new renal dialysis was similar. Blood transfusion (67% vs 36%; P < .0001) and reoperations for bleeding/tamponade (6.4% vs 3.1%; P = .009) were more common after reoperative SAVR. Survival at 1, 5, 10, and 20 years was 94%, 82%, 64%, and 33% after reoperative SAVR and 95%, 86%, 72%, and 46% after elective primary isolated SAVR.

CONCLUSIONS

Risk of mortality and morbidity after reoperative SAVR has declined and is now similar to that of primary isolated SAVR. Decisions regarding prosthesis choice and SAVR versus transcatheter aortic valve replacement should be made in the context of lifelong disease management rather than avoidance of reoperation.

Implementation of a direct-to-operating room aortic emergency transfer program: Expedited management of type A aortic dissection

INTRODUCTION

Type A Aortic Dissection (TAAD) is a surgical emergency with a time-dependent rate of mortality. We hypothesized that a direct-to-operating room (DOR) transfer program for patients with TAAD would reduce time to intervention.

METHODS

A DOR program was started at an urban tertiary care hospital in February 2020. We performed a retrospective study of adult patients undergoing treatment for TAAD before (n = 42) and after (n = 84) implementation of DOR. Expected mortality was calculated using the International Registry of Acute Aortic Dissection risk prediction model.

RESULTS

Median time from acceptance of transfer from emergency physician to operating room arrival was 1.37 h (82 min) faster in DOR compared to pre-DOR (1.93 h vs 3.30 h, p < 0.001). Median time from arrival to operating room was 1.14 h (72 min) faster after DOR compared to pre-DOR (0.17 h vs 1.31 h, p < 0.001). In-hospital mortality was 16.2% in pre-DOR, with an observed-to-expected (O/E) ratio of 1.03 (p = 0.24) and 12.0% in the DOR group, with an O/E ratio of 0.59 (p < 0.001).

CONCLUSION

Creation of a DOR program resulted in decreased time to intervention. This was associated with a decrease in observed-to-expected operative mortality. The transfer of patients with acute type A aortic dissection to centers with direct-to-OR programs may result in decreased time from diagnosis to surgery.

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.

Avascular midline oropharyngeal anatomy allows for expanded indications for transoral robotic surgery in pediatric patients

Transoral robotic surgery (TORS) in children is in its infancy, and indications have been primarily limited to lingual tonsillar hypertrophy and superficial mucosal lesions. However, the relatively avascular channel of the midline posterior tongue, vallecula, and posterior hyoid space provides a safe plane of dissection for deep lesions of the tongue and access to structures in the anterior neck. As robotic surgeons gain experience, application of this technology will continue to grow. The method is retrospective case series. We present seven patients who had either a primary (n = 3) or recurrent (n = 4) lingual thyroglossal duct cyst (TGDC) and underwent TORS excision. Four of the seven patients also underwent transoral resection of the central portion of the hyoid bone, while three had central hyoid resection during prior surgery. Two minor complications occurred with no evidence of lesion recurrence after mean follow-up of 19.7 mo. The midline avascular channel of the tongue allows for relatively bloodless surgical access to pathologies of the midline base of tongue and anterior neck. Lingual thyroglossal duct cysts can safely be removed via a TORS approach with evidence of limited recurrence. Robotic technology can provide safe and effective surgical alternatives for children with a variety of pathologies, and we aim to promote the widespread adoption of TORS in pediatric head and neck surgery by sharing our knowledge and clinical experience. Further study and publication are needed to establish safety and efficacy.

Perioperative outcomes in children with Hashimoto's thyroiditis undergoing total thyroidectomy

BACKGROUND

Hashimoto's thyroiditis (HT) affects 1-2 % of the pediatric population. In adults with HT, thyroidectomy is considered challenging and prone to postoperative complications due to the chronic inflammatory process. However, the complications of thyroidectomy among children with HT have not been established. The objective of our study was to evaluate whether children with HT undergoing total thyroidectomy for presumed thyroid cancer have higher complication rates than children without HT.

METHODS

A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 2014 and 2021.

RESULTS

111 patients met inclusion criteria, 15 of these were diagnosed with HT preoperatively. Operative time and length of admission were similar among the groups. Postoperatively, patients with HT were more likely to have low levels of parathyroid hormone (60 % vs 26 %, p = 0.014) and transient hypocalcemia compared to non-HT patients, present with symptomatic hypocalcemia (67 % vs 27 %, p = 0.006), demonstrate EKG changes (20 % vs 6.3 %, p = 0.035) within 24 h of surgery, and to require both oral and intravenous calcium supplements (80 % vs 35 %, p = 0.001 and 60 % vs 22 % p = 0.004 respectively). Persistent hypocalcemia at 6 months follow-up, and recurrent laryngeal nerve paralysis rates were similar between groups. Parathyroid tissue was found in the thyroid specimen of 9 (60 %) HT patients vs 34 (35 %) non-HT patients (p = 0.069).

CONCLUSIONS

The risk of permanent complications among children with HT following thyroidectomy is low. However, patients with HT are more likely to develop symptomatic transient hypocalcemia and to require oral and intravenous calcium supplements in the immediate post-operative period compared to non-HT patients. Tailoring a perioperative treatment protocol to optimize calcium levels may be considered for children with HT.

Redefining "low risk": Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era

OBJECTIVES

Guidelines suggest aortic valve replacement (AVR) for low-risk asymptomatic patients. Indications for transcatheter AVR now include low-risk patients, making it imperative to understand state-of-the-art surgical AVR (SAVR) in this population. Therefore, we compared SAVR outcomes in low-risk patients with those expected from Society of Thoracic Surgeons (STS) models and assessed their intermediate-term survival.

METHODS

From January 2005 to January 2017, 3493 isolated SAVRs were performed in 3474 patients with STS predicted risk of mortality <4%. Observed operative mortality and composite major morbidity or mortality were compared with STS-expected outcomes according to calendar year of surgery. Logistic regression analysis was used to identify risk factors for these outcomes. Patients were followed for time-related mortality.

RESULTS

With 15 observed operative deaths (0.43%) compared with 55 expected (1.6%), the observed:expected ratio was 0.27 for mortality (95% confidence interval [CI], 0.14-0.42), stroke 0.65 (95% CI, 0.41-0.89), and reoperation 0.50 (95% CI, 0.42-0.60). Major morbidity or mortality steadily declined, with probabilities of 8.6%, 6.7%, and 5.2% in 2006, 2011, and 2016, respectively, while STS-expected risk remained at approximately 12%. Mitral valve regurgitation, ventricular hypertrophy, pulmonary, renal, and hepatic failure, coronary artery disease, and earlier surgery date were residual risk factors. Survival was 98%, 91%, and 82% at 1, 5, and 9 years, respectively, superior to that predicted for the US age-race-sex-matched population.

CONCLUSIONS

STS risk models overestimate contemporary SAVR risk at a high-volume center, supporting efforts to create a more agile quality assessment program. SAVR in low-risk patients provides durable survival benefit, supporting early surgery and providing a benchmark for transcatheter AVR.

Aortic Valve Reconstruction With Autologous Pericardium Versus a Bioprosthesis: The Ozaki Procedure in Perspective

Background We assessed the Ozaki procedure, aortic valve reconstruction using autologous pericardium, with respect to its learning curve, hemodynamic performance, and durability compared with a stented bioprosthesis. Methods and Results From January 2007 to January 2016, 776 patients underwent an Ozaki procedure at Toho University Ohashi Medical Center. Learning curves, aortic regurgitation (AR), and peak gradient, assessed by serial echocardiograms, valve rereplacement, and survival were investigated. Valve performance and durability were compared with 627 1:1 propensity-matched patients receiving stented bovine pericardial valves implanted from 1982 to 2011 at Cleveland Clinic. Learning curves were observed for aortic clamp and cardiopulmonary bypass times, AR prevalence, and early mortality. Decreased aortic clamp time was observed over the first 300 cases. New surgeons performing parts of the procedure after case 400 resulted in a slight increase in aortic clamp and cardiopulmonary bypass times. Among matched patients, the Ozaki cohort had more AR than the PERIMOUNT cohort (severe AR at 1 and 6 years, 0.58% and 3.6% versus 0.45% and 1.0%, respectively; P[trend]=0.006), although with a steep learning curve. Peak gradient showed the opposite trend: 14 and 17 mm Hg for Ozaki and 24 and 28 mm Hg for PERIMOUNT at these times (P[trend]<0.001). Freedom from rereplacement was similar (P=0.491). Survival of the Ozaki cohort was 85% at 6 years. Conclusions Patients undergoing the Ozaki procedure had lower gradients but more recurrent AR than those receiving PERIMOUNT bioprostheses. Although recurrent AR is concerning, results confirm low risk and good midterm performance of the Ozaki procedure, supporting its continued use.

Surgery for Aneurysmal Coronary Artery Fistulas to the Coronary Sinus in Adults

Surgical treatment of aneurysmal distal congenital coronary artery fistulas depends on size and anatomy. From 2008 to 2021, we applied a new surgical technique in 7 adult patients: proximal and distal fistula closure, opening of aneurysmal artery, and revascularization of branches rising from the fistula under cardiopulmonary bypass and cardiac arrest. (Level of Difficulty: Intermediate.)

Ultra-Hybrid Repair: Open Thoracoabdominal Completion After Descending Stent Grafting

To characterize patient risk profiles and outcomes associated with staged ultra-hybrid repair of extensive aortic disease, in which open thoracoabdominal completion was performed after thoracic stent grafting. From 1/2006 to 1/2021, 92 patients underwent open thoracoabdominal repair of chronic dissection (n=58, 63%), degenerative aneurysm (n=28, 30%), endoleak (n=4, 4.3%), or symptomatic acute type B dissection (n=2, 2.2%) after descending thoracic stent grafting (69, 75%), frozen elephant trunk (5, 5%), or both (18, 20%). The surgical graft was sewn to the distal endovascular device in situ, reducing the extent of the open procedure and eliminating the need for hypothermic circulatory arrest. Mean age was 58±13 years, 89 (97%) were hypertensive, 38 (43%) had chronic obstructive pulmonary disease, 63 (72%) were smokers, 20 (24%) had a prior stroke, and 33 (36%) had a suspected or confirmed heritable aortic condition. Hospital mortality was 7.6% (n=7). Complications included dialysis (16, 20%), tracheostomy (8, 8.7%), stroke (5, 5.7%), and permanent paralysis (6, 6.9%). Survival at 1, 3, and 5 years was 80%, 71%, and 66%, respectively. Mortality was associated with higher blood urea nitrogen and longer distance between the distal endograft edge and proximal patent visceral vessel (P=0.004 and .01, respectively). Patients with extensive aortic disease undergoing open aortic repair after thoracic stent grafting are often young with chronic dissection, multiple comorbidities, or a heritable aortic condition. Success of staged ultra-hybrid operations demonstrates open and endovascular repair strategies are complementary, even when performed in a high-risk patient population.

Two-year outcomes after transcatheter aortic valve-in-valve implantation in degenerated surgical valves

BACKGROUND

Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has emerged in recent years as a safe alternative to redo surgery in high-risk patients. Although early results are encouraging, data beyond short-term outcomes are lacking. Herein, we aimed to assess the 2-year outcomes after ViV-TAVI.

METHODS

Patients undergoing ViV-TAVI for degenerated surgical valves between 2013 and 2019 at the Cleveland Clinic were reviewed. The coprimary endpoints were all-cause mortality and congestive heart failure (CHF) hospitalizations. We used time-to-event analyses to assess the primary outcomes. Further, we measured the changes in transvalvular gradients and the incidence of structural valve deterioration (SVD).

RESULTS

One hundred and eighty-eight patients were studied (mean age = 76 years; 65% males). At 2 years of follow-up, all-cause mortality and CHF hospitalizations occurred in 15 (8%) and 28 (14.9%) patients, respectively. On multivariable analysis, the postprocedural length of stay was a significant predictor for both all-cause mortality (hazard ratio [HR] = 1.1; 95% confidence interval [CI]: 1.01, 1.19) and CHF hospitalization (HR = 1.16; 95% CI: 1.07, 1.27). However, the internal diameter of the surgical valve was not associated with significant differences in both primary endpoints. For hemodynamic outcomes, nine patients (4.8%) developed SVD. The mean and peak transvalvular pressure gradients remained stable over the follow-up period.

CONCLUSION

ViV-TAVI for degenerated surgical valves was associated with favorable 2-year clinical and hemodynamic outcomes. Further studies are needed to better understand the role of ViV-TAVI as a treatment option in the life management of aortic valve disease.

Valve-Preserving Root Reimplantation Combined with Arch Procedure: Optimizing Patient Selection

OBJECTIVE

Patients with thoracic aortic disease commonly present with concomitant multisegment pathology. We describe the patient population, analyze outcomes, and define the patient selection strategy for valve-preserving aortic root reimplantation (VPARR) combined with the arch procedure. Methods: From 2008 to 2018, 98 patients underwent VPARR combined with the aortic arch procedure (hemi-arch, 50% [n = 49, limited repair]; total arch, 50% [n = 49, complete repair] including 39 with elephant trunk). Indications for surgery were aneurysmal disease (61%) and aortic dissection (39%). The median follow-up was 17 months (IQR, 8 to 60 months). Results: There were no operative deaths or paraplegia, and 5 patients underwent re-exploration for bleeding. During follow-up, 2 patients required aortic valve replacement for severe aortic insufficiency at 1 and 5 years, and 4 patients died. In the limited repair group, 1 patient underwent reintervention for aortic arch replacement, whereas 4 patients underwent planned intervention (1 endovascular and 3 open thoracoabdominal aortic repair). In the complete repair group, 23 patients underwent planned intervention (15 endovascular and 8 open thoracoabdominal repair). Conclusions: Single-stage, complete, proximal aortic repair including VPARR combined with total aortic arch replacement is as safe and feasible to perform as limited arch repair and facilitates further intervention in carefully selected patients with diffuse aortic pathology at centers of expertise.

ARISE: First-In-Human Evaluation of a Novel Stent Graft to Treat Ascending Aortic Dissection

BACKGROUND

Operative mortality for type A aortic dissection is still 10-20% at centers of excellence. Additionally, 10-20% are not considered as viable candidates for open surgical repair and not offered life-saving emergency surgery. ARISE is a multicenter investigation evaluating the novel GORE® Ascending Stent Graft (ASG; Flagstaff, AZ).

OBJECTIVE

The purpose of this study is to assess early feasibility of using these investigational devices to treat ascending aortic dissection.

METHODS

This a prospective, multicenter, non-randomized, single-arm study that enrolls patients at high surgical risk with appropriate anatomical requirements based on computed tomography imaging at 7 of 9 US sites. Devices are delivered transfemorally under fluoroscopic guidance. Primary endpoint is all-cause mortality at 30 days. Secondary endpoints include major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, 6 months, and 12 months.

RESULTS

Nineteen patients were enrolled with a mean age of 75.7 years (range 47-91) and 11 (57.9%) were female. Ten (52.6%) had DeBakey type I disease, and the rest were type II. Sixteen (84.2%) of the patients were acute. Patients were treated with safe access, (7/19 (36.8%) percutaneous, 10/19 (52.6%) transfemoral, 2/19 (10.5%) iliac conduit), delivery, and deployment completed in all cases. Median procedure time was 154 mins (range 52-392) and median contrast used was 111 mL (range 75-200). MACCE at 30 days occurred in 5 patients including mortality 3/19 (15.8%), disabling stroke in 1/19 (5.3%), and myocardial infarction in 1/19 (5.3%).

CONCLUSION

Results from the ARISE early feasibility study of a specific ascending stent graft device to treat ascending aortic dissection are promising.

Comparison of Outcomes of Patients Undergoing Reimplantation versus Bentall Root Procedure

Background  A bioprosthesis- or mechanical-prosthesis–containing polyester graft (composite graft) is standard surgical management for aortic root aneurysms (Bentall procedure), but particularly in the young patient in whom a bioprosthesis is likely to deteriorate and a mechanical prosthesis mandates life-long anticoagulation, valve-sparing procedures have been devised. One such procedure involves reimplantation of the native aortic valve in the polyester graft. With focus on selecting the optimum procedure for young relatively asymptomatic patients, we compared outcomes of reimplantation of the aortic valve versus the Bentall procedure and identified factors influencing outcomes.

Methods  From January 2000 to January 2017, 643 adults age ≤ 70 with tricuspid aortic valves underwent elective aortic root replacement with either reimplantation ( n  = 448/70%) or a composite valve graft (Bentall) procedure ( n  = 195/30%). Outcomes were compared in 100 propensity-matched pairs.

Results  Patients with fewer symptoms, less aortic regurgitation (AR), higher left ventricular ejection fraction, and smaller cross-sectional aortic area/height ratio had a higher likelihood of valve repair with reimplantation (all p  < 0.02) versus receiving a Bentall procedure. Operative mortality was 0.16% (reimplantation, 1/448, 0.22%; Bentall 0/195, 0%). After reimplantation, 8-year freedom from severe AR was 95% and 10-year freedom from reintervention was 98%. Ten-year survival was 95%. Higher preoperative AR grade ( p  < 0.0001) but not larger root diameter ( p  = 0.3) was associated with higher grade of late regurgitation after a reimplantation procedure. Among propensity-matched patients, reimplantation compared with a Bentall was associated with similar 10-year survival (89% vs. 94%), but more late AR (8-year freedom from severe AR: 93% vs. 99.9%) and greater early reduction in, but similar late, left ventricular mass (104 vs. 105 g•m ^–2 at 8 years).

Conclusion  Excellent aortic valve reimplantation results versus Bentall lead us to recommend reimplantation more often in patients who present with even moderately severe or severe AR and significantly enlarged aortic roots.

Improvements in Outcomes and Expanding Indications for the Commando Procedure. Comment on Giambuzzi et al. Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results. J. Clin. Med. 2021, 10, 3163

We read with interest the authors' review and metanalysis of the Commando procedure in "Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results" [...].

Aortic root replacement with bicuspid valve reimplantation: Are outcomes and valve durability comparable to those of tricuspid valve reimplantation?

OBJECTIVES

To assess intermediate-term outcomes of aortic root replacement with valve-sparing reimplantation of bicuspid aortic valves (BAV), compared with tricuspid aortic valves (TAV).

METHODS

From January 2002 to July 2017, 92 adults underwent aortic root replacement with BAV reimplantation and 515 with TAV reimplantation at the Cleveland Clinic. Balancing-score matching based on 28 preoperative variables yielded 71 well-matched BAV and TAV pairs (77% of possible pairs) for comparison of postoperative mortality and morbidity, longitudinal echocardiogram data, aortic valve reoperation, and survival.

RESULTS

In the BAV group, 1 hospital death occurred (1.1%); mortality among all reimplantations was 0.2%. Among matched patients, procedural morbidity was low and similar between BAV and TAV groups (1 stroke in TAV group; renal failure requiring dialysis, 1 patient each; red cell transfusion, 25% each). Five-year results: Severe aortic regurgitation was present in 7.4% of the BAV group and 2.9% of the TAV group (P = .7); 39% of BAV and 65% of TAV patients had none. Higher mean gradients (10 vs 7.4 mm Hg; P = .001) and left ventricular mass index (111 vs 101 g/m2; P = .5) were present in BAV patients. Freedom from aortic valve reoperation was 94% in the BAV group and 98% in the TAV group (P = .10), and survival was 100% and 95%, respectively (P = .07).

CONCLUSIONS

Both BAV and TAV reimplantations can be performed with equal safety and good midterm outcomes; however, the constellation of higher gradients, less ventricular reverse remodeling, and more aortic valve reoperations with BAV reimplantations raises concerns requiring continued long-term surveillance.

Surgical management of parotid non-tuberculous mycobacteria lymphadenitis in children: A pediatric tertiary-care hospital's experience

OBJECTIVE

Non-tuberculous mycobacteria (NTM) represents an important etiology of cervicofacial lymphadenitis (CFL) and skin/soft tissue infections in children. It can also affect the salivary glands, including the parotid gland, which is unique due to the presence of intra-salivary lymph nodes. There are no established guidelines for treatment of NTM CFL. NTM lymphadenitis was historically surgically treated; recently the literature supports initial medical treatment. Treatment decisions have been dependent on the extent of disease, preference of providers, and risk of surgical complications. The goal is to report our experience in surgical outcomes of NTM CFL with involvement of the parotid gland after pre-operative medical management.

METHODS

A retrospective case series of patients with NTM affecting the parotid gland at a tertiary care pediatric hospital between 2004 and 2020.

RESULTS

Seventy-two patients were referred for surgical evaluation of possible parotid NTM. Thirty-three patients underwent surgical excision. Fifteen patients were identified with presumed NTM infection involving the parotid gland. There were twelve females and three males with a mean age of 2.0 years (SD 1.55; range 1-6 days) at the time of surgery. All underwent surgical excision with parotidectomy. The most common pre-operative antimycobacterial therapy used was a combination of clarithromycin and rifampin. All 15 patients had pathological findings consistent with NTM infection (granulomatous lymphadenitis). Forty percent (n = 6) of patients had positive stains with acid-fast bacilli (AFB), with Mycobacterium avium as the most common species (n = 5). The majority of patients, 86.67% (n = 13), had complete resolution of infection after surgery. Clarithromycin and rifampin were the most common post-operative antimycobacterial treatment (mean 81.5 days, SD 110.14, range 2-411 days). The most common complication experienced was acute (<3 months) lower facial nerve paresis (40%, n = 6), but no patient had permanent facial paralysis.

CONCLUSION AND RELEVANCE

Parotidectomy is a safe and efficacious treatment in patients with NTM CFL affecting the parotid gland after incomplete resolution with antimycobacterial therapy. Further investigation to optimize duration of antimycobacterial treatment is necessary. We highlight the experience of a high-volume tertiary care pediatric hospital with surgical management of this disease.

Refractory Recurrent Pericarditis After Pericardiectomy in a Young Woman

Pericardiectomy is the recommended treatment for patients with recurrent pericarditis and refractory symptoms despite optimal anti-inflammatory therapy. We present a case of a 40-year-old woman who underwent total pericardiectomy after multiple episodes of pericarditis that was refractory to optimal guideline-derived medical therapy, including anti-inflammatory and biologic agents, who continued to have relapsing symptoms even after pericardiectomy. (Level of Difficulty: Intermediate.)

Cardiac Operations after Transcatheter Aortic Valve Replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is now frequently performed for severe aortic stenosis. Data regarding cardiac operations after TAVR are limited, however. Therefore, we investigated patient characteristics, operative timing and indications, and outcomes of these operations in a single-center experience.

METHODS

From 1/2012-7/2020, 59 patients (median age 70) underwent cardiac operations after TAVR, 38 (64%) of the latter performed outside our center. Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was calculated at time of prior TAVRs and at applicable index cardiac operations.

RESULTS

From 2012-2018, there were fewer than 10 operations after TAVR, but 18 in 2019. Interval between prior TAVR and cardiac surgery decreased exponentially from 7 to less than 1 year over the experience. In applicable cases (n=19; 32%), median STS-PROM was 5.5% (15^th-85th percentiles, 3.1%-25%); 40 (68%) were complex operations with no calculable STS-PROM. The TAVR valve was explanted in 46 (78%); 5 were isolated surgical AVRs. TAVR valve stenosis/regurgitation (n=34; 58%) was the leading indication, followed by paravalvular leak (14; 24%) and endocarditis (n=10/17%). When the TAVR valve was not explanted, mitral regurgitation was the leading indication for operation. Operative mortality was 5 (8.5%), postoperative stroke 2 (3.4%), and postoperative dialysis 6 (10%).

CONCLUSIONS

Cardiac operations after TAVR are increasing and interval between TAVR and operation decreasing. Most cardiac operations are complex, high-risk reoperations and isolated AVR rare. These findings should be considered when TAVR is selected for low-intermediate risk patients, particularly with multiple cardiac pathologies not addressed by TAVR.

Radical pericardiectomy for pericardial diseases

Pericarditis is the most common form of pericardial disease. Its exact incidence remains unknown, probably because many cases resolve without diagnosis. Indications for pericardiectomy from the standpoint of the cardiac surgeon are based mainly on the physiopathology of 2 different entities that can overlap: inflammatory or relapsing pericarditis and constrictive pericarditis. Surgical indications are not always straightforward. Patients with inflammatory or relapsing pericarditis may undergo radical pericardiectomy because they experience severe symptoms despite maximal medical treatment or have sequelae from the medical treatment. Pericardiectomy is the standard treatment in patients with chronic constrictive pericarditis and persistent symptoms who are in New York Heart Association functional class III or IV and a class I recommendation in the European Society of Cardiology/European Association of Cardio-Vascular Surgery guidelines. The goal of surgery is always complete removal of any site of inflammation through a radical pericardiectomy.

Right Internal Thoracic Artery Patency Is Affected More by Target Choice Than Conduit Configuration

BACKGROUND

Although coronary artery bypass grafting using bilateral internal thoracic arteries (BITA) maximizes long-term survival, knowledge of the effect of different right ITA (RITA) inflow configurations on graft patency is limited. We have compared RITA occlusion among these configurations and identified its risk factors while adjusting for outflow coronary target location.

METHODS

From 1/1972-1/2016, of 7,092 patients undergoing BITA grafting at a single center, 1,331 received 1 ITA to the left anterior descending coronary artery (LAD) and had ≥1 evaluable postoperative coronary angiograms: 835 (63%) in-situ, 496 free-RITA grafts (311 [63%] originating from aorta, 98 [20%] left internal thoracic artery (LITA), 76 [15%] saphenous vein graft [SVG], 11 [2%] radial graft). RITA occlusion reported on 1,983 angiograms performed a median of 5.8 years later was estimated using nonlinear mixed-effects longitudinal modeling.

RESULTS

RITA patency was 90% at 1 year, 87% at 5 years, and 86% at 10 and 15 years. At 15 years, in-situ RITA patency was 91% and free RITA patency from aorta 91%, LITA 89%, and SVG 77%. After adjusting for coronary target location and degree of stenosis, occlusion was similar in free RITAs from aorta (P=.15), LITA (P=.4), SVG (P=.13), and in-situ RITAs. However, RITAs grafted to the LAD had fewer occlusions (P<.001), with patency similar to LITAs.

CONCLUSIONS

Among patients with BITA grafting requiring interval coronary angiography, long-term RITA patency was high and independent of its inflow configuration. Therefore, priority should be a RITA configuration optimizing its reach to important coronary targets, including the LAD.

Risks and Outcomes of Reoperative Cardiac Surgery in Patients with Patent Bilateral Internal Thoracic Artery Grafts

BACKGROUND

Reoperative cardiac surgery in patients with patent bilateral internal thoracic arteries (ITA) grafts is technically challenging.

METHODS

From 2008-2017, of 7,640 patients undergoing reoperative cardiac surgery, 116 (1.5%) had patent bilateral ITA grafts, including 28 with a right ITA crossing the midline. Mean age was 70±9.6 years, and 111 patients (96%) were male. Reoperations included isolated coronary artery bypass grafting (CABG; n=11), isolated valve (n=55), valve+CABG (n=26), and other procedures (n=24). Clinical details, intraoperative management, and perioperative outcomes were analyzed.

RESULTS

Aortic cannulation was central in 64 patients (56%) and via femoral or axillary artery in 50 (44%). Four patients (3.4%) had planned transection and reattachment of ITAs crossing the midline, and 4 (3.4%) had ITA injuries, all right ITAs, 3 crossing the midline; 3 were repaired with an interposition vein graft, and 1 was managed by translocating the right ITA as a Y-graft off another graft. Patent ITAs were managed by atraumatic occlusion during aortic clamping in 90 patients (78%) and by systemic cooling without ITA occlusion in 19. There were 6 operative deaths, all due to low cardiac output syndrome (5.2%), 4 strokes (3.4%), and 5 cases of new postoperative dialysis (4.3%).

CONCLUSIONS

Risk of injury to bilateral ITA grafts during reoperation is high, and right ITAs crossing the midline present a particular risk of injury and should inform planning for primary CABG. Risk of low cardiac output syndrome underscores the challenge of ensuring adequate myocardial protection.

Outcomes of Open v. Endovascular Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms

BACKGROUND

Open repair is the standard of care for patients with descending thoracic and thoracoabdominal aortic aneurysms. Although effective, surgery carries a high risk of morbidity and mortality. Endovascular stent-grafts were introduced to treat these aneurysms in patients considered too high risk for open repair. Early results are promising, but later results are incompletely known. Therefore, we sought to compare short- and intermediate-term outcomes of open versus endovascular repair for these aneurysms.

METHODS

From 2000-2010, 1,053 patients underwent open (n=457) or endovascular (n=596) repair of descending thoracic and thoracoabdominal aortic aneurysms at Cleveland Clinic. To balance patient characteristics between these groups, propensity-score matching was performed, yielding 278 well-matched pairs (61% of possible pairs). Endpoints included short- and long-term outcomes.

RESULTS

In matched patients, compared with endovascular stenting, open repair achieved similar in-hospital mortality (n=23/8.3% vs n=21/7.6%, P=.8) and occurrence of paralysis and stroke (n=10/3.6% vs n=6/2.2%, P=.3), despite longer postoperative stay (median 11 vs 6 days), more dialysis-dependent acute renal failure (n=24/8.6% vs n=9/3.3%, P=.008), and prolonged ventilation (n=106/46% vs n=17/6.3%, P<.0001). Open repair resulted in better 10-year survival than endovascular repair (52% vs 33%, P<.0001), and aortic reintervention was less frequent (4% vs 21%, P<.0001). Despite a decrease in the first postoperative year, average aneurysm size did not recover to normal range after endovascular stenting.

CONCLUSIONS

Open repair of descending thoracic and thoracoabdominal aneurysms can achieve acceptable short-term outcomes with better intermediate-term outcomes than endovascular repair.

Modern practice and outcomes of reoperative cardiac surgery

OBJECTIVES

To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest.

METHODS

From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect.

RESULTS

Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2).

CONCLUSIONS

Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.

Similar long-term survival after isolated bioprosthetic versus mechanical aortic valve replacement: A propensity-matched analysis

OBJECTIVES

Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement.

METHODS

From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients.

RESULTS

Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P > .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P < .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] < .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group.

CONCLUSIONS

Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.

Effect of Dedicated In-Person Interpreter on Satisfaction and Efficiency in Otolaryngology Ambulatory Clinic

OBJECTIVE

In a large academic children's hospital ambulatory clinic, the increasing demand for Spanish interpretation exceeds the Interpreting Services Department capacity, necessitating telephone interpretation. By adding a dedicated Spanish interpreter in the otolaryngology clinic, we aimed to decrease visit times for Spanish-speaking patients and increase satisfaction. Additional aims explored if dedicated Spanish interpreters could increase patients seen per session.

METHODS

A quality improvement initiative investigated baseline state compared to 2 tests of change using video interpretation and dedicated, in-person interpretation. Time permitting, interpreters contacted patients before the visit to decrease missed appointments and late arrivals. Measures included clinic visit times, late arrivals, missed appointments, and family/employee satisfaction scores. Actuarial statistics forecasted if on-site Spanish interpreters would affect patients seen per session and the potential addition of sessions.

RESULTS

In-person interpretation reduced visit times for Spanish-speaking patients from 55 to 48 minutes (P = .01) and 57 to 48 minutes for all patients (P < .0001). Nearly 50% of video calls experienced technical difficulties. Families and employees preferred in-person over video and phone interpretation. No-show visits decreased by 25% and late arrivals by 17%.

DISCUSSION

Implementing dedicated Spanish interpreters may increase productivity and enhance family experience.

IMPLICATIONS FOR PRACTICE

Reducing patient visit time by 9 minutes permits 2 additional patients per clinic session (1560 visits, 390 surgeries per year). Applied institution-wide, the intervention could create 29% more capacity in the ambulatory schedule (31,000 additional visits) and reduce actuarial need for ambulatory sessions in the same clinic space.

Aortic Valve Replacement in Young and Middle-Aged Adults: Current and Potential Roles of TAVR

BACKGROUND

Contemporary practice patterns and outcomes for aortic valve replacement (AVR) among young and middle-aged adults are unknown given guideline modifications for surgical AVR (SAVR) and increasing transcatheter AVR (TAVR) acceptance. This study describes SAVR and TAVR use and outcomes using The Society of Thoracic Surgeons (STS) National Databases.

METHODS

Adults 18 to 55 years of age in the Congenital Heart Surgery Database (CHSD) and the Adult Cardiac Surgery Database (ACSD) who underwent SAVR or TAVR from 2013 to 2018 were included. Perioperative characteristics and early outcomes were described by valve type. Multivariable regression identified determinants of death, length of hospital stay, and a composite end point of renal failure, persistent neurologic deficit, readmission, and reoperation.

RESULTS

The study analyzed 1580 unique CHSD and 44,173 ACSD operations, 16% of which were performed in patients with congenital heart disease. Valve use included the following: TAVR, 1%; mechanical, 42%; bioprosthetic, 55%; autograft, 0.6%; homograft, 1.2%; and Ozaki, 0.4%. Over time, TAVR volumes increased by 167%. The 30-day mortality was as follows: TAVR, 3.8%; mechanical, 3.2%; bioprosthetic, 3.7%; autograft, 0.6%; homograft, 9%; and Ozaki, 3.4%. Stroke rate was lower for isolated SAVR vs isolated TAVR (0.9% vs 2.4%; P = .002). In multivariable analyses, mortality risk was lower with mechanical valves, congenital morbidity risk was higher with TAVR, and length of stay was shorter with TAVR.

CONCLUSIONS

TAVR is increasingly used for adults younger than 55 years of age. Given the uniformly excellent results with SAVR, including both mortality and morbidity-particularly regarding stroke, our data favor SAVR in this population, but a prospective trial is needed. Ongoing efforts to harmonize variables and outcomes definitions between the ACSD and CHSD are valuable.

Impact of Endovascular False Lumen Embolization on Thoracic Aortic Remodeling in Chronic Dissection

BACKGROUND

Retrograde false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for chronic dissection is a mode of treatment failure. Thrombosis of the FL is associated with favorable reverse remodeling. Objectives are to describe FL embolization (FLE) strategy and assess aortic remodeling and survival.

METHODS

From January 2009 to December 2017, 51 patients with chronic dissection underwent FLE, most after previous TEVAR. Devices included a combination of iliac plug (29 patients), coils (19 patients), or nitinol plug (3 patients). Computed tomography was performed before discharge, at 3 months, and annually (median follow-up 2 years [range, 1 month to 7 years]).

RESULTS

After FLE, mean maximum aortic diameter decreased (64.2 ± 12 mm to 61.0 ± 13 mm; P = .03), true lumen diameter increased (24.7 ± 10 mm to 33.7 ± 8 mm; P < .001), and FL diameter decreased (36.7 ± 12 mm to 25.6 ± 15 mm, P < .001). For reverse remodeling, FL thrombosis with ≥10% decrease in diameter and ≥10% increase in true lumen diameter was achieved in 20 (39.2%; 16 primarily, 4 secondarily). Nine patients progressed after the first FLE: persistent FL flow with increase in aortic diameter and underwent repeat FLE with complete thrombosis (n = 4) or open thoracoabdominal completion (n = 5). A total of 26 patients had indeterminate response (FL thrombosis without change in maximum diameter), and none have required reoperation. Six patients had complete obliteration of the entire FL. At last follow-up, 42 (82%) patients were alive. Three deaths were related to aortic pathology.

CONCLUSIONS

FLE is an important endovascular adjunct to TEVAR promoting reverse aortic remodeling in select patients with chronic aortic dissection and persistent retrograde FL perfusion.

Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis

BACKGROUND

Little is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients.

METHODS

From 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion.

RESULTS

Two of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively.

CONCLUSIONS

Among patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.