The Perceval Valve is a true sutureless aortic bioprosthesis. Overall, excellent performances have been demonstrated in terms of hemodynamic outcomes, safety and versatility of use; furthermore, as a sutureless valve option, it has shown to reduce the surgical burden, shortening the operative times and simplifying minimally invasive procedures. Since the valve has got a high frame profile, the recommended implantation technique requires a high and transverse aortotomy. In case of unplanned Perceval valve implantation, when an extended aortotomy is required, we have come up with a simple technique to reshape the aortic root before the valve is delivered in place: symmetry is pivotal to prevent folding issues and to improve the annular sealing. Although we discuss an out-of-recommendation use, in our experience that technique has shown to be safe and effective.
Background: We analysed the results of the modified Bentall procedure in a high-risk group of patients presenting with acute type A aortic dissection (ATAAD). Methods: ATAAD patients undergoing a modified Bentall between 1996 and 2018 (n=314) were analysed. Mechanical composite conduits were used in 45%, and biological using either a bioprosthesis implanted into an aortic graft (33%) or xeno-/ homograft root conduits (22%) in the rest. Preoperative malperfusion was present in 34% of patients and cardiopulmonary resuscitation required in 9%. Results: Concomitant arch procedures consisted of hemiarch in 56% and total arch / elephant trunk in 34%, while concomitant coronary artery surgery was required in 24%. Average crossclamp and cardiopulmonary bypass times were 126 ± 43 and 210 ± 76 minutes, respectively, while average circulatory arrest times were 29 ± 17 minutes. A total of 69 patients (22%) suffered permanent neurologic deficit, while myocardial infarction occurred in 18 cases (6%) and low cardiac output syndrome in 47 (15%). In-hospital mortality rate was 17% due to intractable low cardiac output syndrome (n = 29), major brain injury (n = 16), multiorgan failure (n = 6) and sepsis (n = 2). Independent predictors of in-hospital mortality were critical preoperative state (OR, 5.6; p < 0.001), coronary malperfusion (OR, 3.6; p = 0.002), coronary artery disease (OR, 2.6; p = 0.033) and prior cerebrovascular accident (OR, 5.6; p = 0.002). Conclusions: The modified Bentall operation, along with necessary concomitant procedures, can be performed with good early results in high risk ATAAD patients presenting.
Objectives The risk of poor outcomes is traditionally attributed to biological and physiological processes in cardiac surgery. However, evidence exists that other factors, such as emotional, behavioural, social and functional, are predictive of poor outcomes. Objectives were to evaluate the predictive value of several emotional, social, functional and behavioural factors on four outcomes; death within 90 days, prolonged stay in intensive care, prolonged hospital admission and readmission within 90 days following cardiac surgery. Methods This prospective study included adults undergoing cardiac surgery 2013-2014, including information on register-based socio-economic factors and self-reported health in a nested subsample. Logistic regression analyses to determine the association and incremental value of each candidate predictor variable were conducted. Multiple regression analyses were used to determine the incremental value of each candidate predictor variable, as well as discrimination and calibration based on AUC and Brier score. Results Of 3217 patients, 3% died, 9% had prolonged intensive care stay, 51% had prolonged hospital admission and 39% were readmitted to hospital. Patients living alone (OR, 1.19; 95% CI, 1.02-1.38), with lower educational levels (1.27; 1.04-1.54) and low health-related quality of life (1.43; 1.02-2.01) had prolonged hospital admission. Analyses revealed living alone as predictive of prolonged ICU stay (Brier, 0.08; AUC, 0.68), death (0.03; 0.71) and prolonged hospital admission (0.24; 0.62). Conclusion Living alone was found to supplement EuroSCORE in predicting death, prolonged hospital admission and prolonged ICU stay following cardiac surgery. Low educational level and impaired health-related quality of life were, furthermore, predictive of prolonged hospital admission.
Coronavirus 2019 (COVID 19) captured worldwide attention as the virus spread from initial detection as a pneumonia of unknown cause in Wuhan, China in December 2019 to the declaration of a pandemic by the World Health Organization only three months later. This paper describes the impact of COVID 19 on cardiac surgery services in the greater Los Angeles area. Discussion includes public health response to the pandemic, how local hospitals reacted to the expected surge in COVID patients, establishment of telemedicine services, and the projected future impact on California healthcare as a result of the COVID 19 pandemic.
Background:The advent of TAVR changed the practice for treating patients with severe aortic stenosis. Heart-Teams improved their decision-making process to refer patients to the best and safest treatment. Evidence allowed centers to increase funding and TAVR volume and extend indications to different risk category of patients. This study evaluates the outcomes of intermediate-risk patients treated for severe aortic stenosis in an academic center. Methods:Between 2012 and 2019, 812 patients with aortic stenosis underwent TAVR or SAVR. A propensity score-matching analytic strategy was used to balance groups and adjust for time periods. Outcomes were recorded according to the Society of Thoracic Surgeons Guidelines; primary outcome being 30-day mortality and secondary outcomes being perioperative course and complications. Results:No difference in mortality was seen but complications differed: more postoperative transient ischemic attacks, permanent pacemaker implantations and perivalvular leaks in the transcatheter group, while more acute kidney injuries, atrial fibrillation, delirium, postoperative infections and bleeding, tamponade and need for reoperation in the surgical group as well as longer hospital length-of-stay. However, over the years, morbidities/mortality decreased for all patients treated for aortic stenosis. Conclusions:Data showed an improvement in morbidities/mortality for intermediate risk patients treated with SAVR or TAVR. Increased funding allowed for higher TAVR volume by increasing access to this technology. Also, the difference in complications could impact healthcare cost. By incorporating important metrics such as length-of-stay, readmission rates and complications into decision-making, the Heart-Team can improve clinical outcomes, healthcare economics and resource utilization.
Chow et al (1) report that significant financial resources are spent on surgical AF ablation in Canada with unclear long-term benefits and “scientifically rigorous” data regarding reduction in mortality and stroke risks. The authors call for large prospective studies examining clinically important outcomes to justify the routine use of concomitant surgical AF ablation (SA) and to guide allocation of healthcare funds. Based on their analysis, they assert that concomitant surgical AF ablation during cardiac surgery should be reconsidered. To better put these findings into context, it is important to examine the assumptions made and data utilized to assess both cost and benefit.The authors admit that their methods for cost derivation are significantly limited and do not “constitute the precision of a detailed prospective cost-utility analysis.” However, even their “simple methods” are incomplete and miss important alternative costs if SA is abandoned. They describe the incremental costs associated with surgical ablation of AF in a specific geographic location - Ontario (Canada). The authors aggregate costs from a variety of sources but base much of their calculations on an increased hospital length of stay (LOS) and increased pacemaker implantation rate from a recent systematic review and meta-analysis of RCTs of surgical ablation of AF (2).This systematic review describes an increased hospital LOS of ~ 1.67 days and a trend (not statistically significant) of increased permanent pacemaker implantation at hospital discharge, although risk of pacemaker implantation was not increased in the long term. Using this information plus Ontario-specific information of institutional costs, physician remuneration and device costs, they generate Ontario-specific financial costs for the procedure and calculate the incremental cost associated with this intervention as $4287 CAD per patient. The authors state that their calculations likely underestimate the true cost of surgical AF ablation but that at least over $10 million (CAD) was spent in Ontario province on surgical AF ablation between 2006-2017. The authors fail to consider, however, the alternative costs associated with NOT performing SA in patients with AF undergoing surgery. While surgery for the primary structural abnormality may alleviate the patients’ symptoms, it is likely that patients with pre-existing AF will continue to have AF if SA is not performed. Patients whose AF is left untreated could continue to have symptoms related to AF necessitating multiple procedures, including cardioversions, hospitalization for initiation of antiarrhythmic drugs, and catheter ablation. Even patients with asymptomatic to minimally symptomatic AF are often treated with this multiplex of therapies, each of which has more limited efficacy than SA. Given the likelihood of multiple treatments and procedures if SA is not performed, any clinically relevant cost analysis must incorporate this real cost. Consequently, the true incremental cost of SA is likely substantially less than the numbers generated by Chow et al.When analyzing the benefits of SA, the conclusions draw heavily from a recent systematic review and meta-analysis that describes several key points regarding surgical AF ablation: 1) surgical AF ablation during cardiac surgery improved freedom from AF at 12 months; 2) there was no statistically significant evidence of impact on mortality, thromboembolic or neurovascular events with limited long-term follow-up; and 3) the evidence for improvement in health-related quality of life was limited (2). It is important to note that of the 23 studies in this meta-analysis, only 5 had follow-up >12 months and only 1 > 24 months. This reported time frame may be inadequate to detect significant differences in clinical outcomes, particularly long-term outcomes such as incident stroke and mortality.As a comparison, in the world of catheter-based ablation, we have recently had the results of the CABANA trial (3). In the intention-to-treat analysis, this trial did not demonstrate statistically significant differences between catheter ablation and anti-arrhythmic drug therapy with regard to the primary composite endpoint of death, disabling stroke, serious bleeding, or cardiac arrest. However, there was a substantial and clinically important benefit of catheter ablation over drug therapy in reducing recurrent symptomatic and asymptomatic AF over 5 years of follow-up (4). There were also clinically important and significant improvements in quality of life (QOL) at 12 months in symptomatic patients (5). There was also a signal for decreased cardiovascular hospitalizations, although not centrally adjudicated, and there may be a signal for mortality benefit of catheter ablation in the subgroup of patients with systolic dysfunction (6). On-treatment analysis showed even more significant benefits, even with mortality reduction.Currently, the American Heart Association and the European Society of Cardiology provide a Class IIa recommendation for concomitant surgical AF ablation to maintain sinus rhythm in symptomatic patients. The guidelines consider surgical AF ablation with cardiac surgery a “reasonable” treatment, including patients with persistent or permanent AF (7, 8). The recent 2017 STS guidelines outline that concomitant surgical ablation to restore normal sinus rhythm during mitral valve procedures is a Class 1 recommendation, level of evidence A. Similarly, surgical ablation at the time of isolated AVR and AVR with CABG is a Class 1 recommendation, level of evidence B-NR (9).We believe the authors’ suggestion that the incremental cost of surgical AF ablation, based on this incomplete analysis, is too great to be shouldered by the taxpayers of Canada is unjustified. This manuscript touches on some interesting topics regarding the rendering of medical care, namely – what patient outcomes justify the financial costs of a procedure and what bar do we set for the level of evidence needed to justify the performance of a procedure but their cost-benefit analysis is incomplete requiring careful reevaluation of its conclusions.The importance of freedom from AF and protection from AF relapses for patients, in particular those with symptomatic AF, cannot be underestimated. Both catheter ablation studies such as CABANA and studies of surgical ablation support a clear decrease in AF burden with ablation. In CABANA, freedom from AF was long-lasting with the benefit of ablation sustained, although attenuated, at 5-year follow-up. Interestingly, the CABANA trial also included patients who had MI, PCI, or valve/bypass surgery > 3 months prior to enrollment although we do not have subgroup-specific data. In regard to freedom from AF, the surgical ablation data from the referenced meta-analysis only extends on average to 12 months (2), but we cannot exclude the possibility of a more sustained treatment effect like that seen in CABANA. In a study of SA, risk-adjusted survival differences were assessed in 372 propensity matched pairs; at last follow-up, 78% of SA patients were free of AF, and restoration of sinus rhythm was associated with improved survival (10). While large-scale data on mortality following SA remain sparse, the Society of Thoracic Surgeons’ report of over 28,000 propensity score matched patients with and without SA support improved survival at 30 days (11).There is strong evidence for improved symptoms and quality of life in patients after ablation. In the DISCERN AF study which evaluated symptomatic and asymptomatic episodes of AF pre and post radiofrequency ablation using long-term continuous monitoring, rates of symptomatic AF approached 50% (12). After ablation, arrhythmia events were 3 times more likely to be asymptomatic and the proportion of asymptomatic episodes approached 80%. This was also substantiated by CABANA trial data that showed that when AF recurred after catheter ablation it was more likely to be asymptomatic – at five years, freedom from recurrence of symptomatic AF episodes was ~ 80% (4). Health-related quality of life was also significantly improved at 12 months in the ablation group versus medical therapy (5). In the systematic review from McClure et al, there was a significant difference in physical role functioning post-operatively even though there were only two studies that could be included in the analysis (2). Granted, in patients undergoing cardiac surgery, health-related QOL outcomes are confounded by improvements in treating the underlying heart disease in addition to the restoration of sinus rhythm (13).Overall, the relatively small cost of $4287 CAD per patient, which would represent a much smaller incremental cost when accounting for the subsequent cost for AF treatment if SA is not performed, strongly supports undertaking this procedure despite the small increased risk of pacemaker implantation and increased hospital stay given the known and established benefits of freedom from AF and improvement in symptoms and quality of life. Additionally, the use of this procedure should not be halted since there is short-term and mid-term surgical mortality data that support its use (9-11), and we cannot rule out mortality and stroke benefit over a period of 5 or more years because of the limited data available. In this sense, we agree with the authors that updated long-term outcomes should be pursued to enhance our understanding and to refine decision making.
Type B Aortic Dissection (TBAD) occurs seldomly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of Type A Aortic Dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. Risk factors for TBAD include: aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a Caesarean section prior to intervention is carried out, unless certain indications are present. Due to a scarce number of cases across decades, it is difficult to determine which management is optimal. This article collates knowledge so far on this rare event during pregnancy.
The use of extracorporeal circulation (ECC) for intraoperative cardiopulmonary support during lung transplantation has been increasing in the recent years. Our group previously described a novel hybrid extracorporeal membrane oxygenation (ECMO) circuit for use in lung transplantation. Our novel technique for intraoperative management of this circuit during lung transplantation is described.
Study aim: To determine the relationship between surgeon and hospital procedural volume, and mitral valve repair rates and 30-day mortality for degenerative mitral regurgitation (MR), in Australian cardiac surgical centres. Methods: 4,970 patients who underwent surgery for degenerative MR between January 2008 and December 2017 in the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) Database were retrospectively included. Univariate and multivariate regression analyses examined surgeon and hospital procedural volumes for associations with repair rate and mortality. Results: Repair rates varied widely by caseload; from 56.7% to 80.4% for lowest to highest volume surgeons; and from 52.0% to 76.1% for lowest to highest volume hospitals. Compared to surgeons performing ≤5 procedures/annum, surgeons performing 10.1-20/annum were more likely to repair the valve (OR 2.91, 95% Confidence Interval [CI] 1.50-5.64, p=0.002), particularly if performing >20/annum (OR 3.9, 95% CI 1.62-9.37, p=0.002). Compared to hospitals performing ≤10/annum, those performing any number of procedures >10 demonstrated increased likelihood of repair (caseload 10.1-20/year OR 2.04, 95% CI 1.30-3.20, p=0.002) though odds did not increase above this threshold. Low incidence of 30-day mortality (83 of 4,964, 1.67%) limited analysis of contributing variables; procedural volume did not confer a survival benefit, though mortality rates were lowest for highest volume proceduralists and hospitals. Conclusions: Surgeon and hospital caseload were significantly associated with repair rates of degenerative MR. A threshold minimum of 10 procedures annually for surgeons and hospitals should be utilised to maximise repair rates, and ideally of 20 for surgeons. Mortality was low and may not be significantly impacted by procedural volume.
Background: We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types. Methods: We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observedto-expected (O/E) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio >2 in one operation type with O/E ratio ≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures. Results: Among 37 NY centers, annual center volumes were 220±120 cases for CABG and 190±178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R2 = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio > 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase. Conclusions: In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.
Cardiac intimal sarcoma are extremely rare and aggressive primary malignant cardiac tumors. Here, we reported the case of a young man initially operated for a tumor of the left atrium, causing a dynamic obstruction of the mitral valve and (mis-)diagnosed as a myxoma at the histopathological analysis. Patient presented a local recurrence at 3 months and was reoperated. Pathology revealed this time the presence of an intimal sarcoma. Patient received adjuvant chemotherapy. Despite a good local control, the one-year follow-up PET scan revealed the presence of a metastasis in the left adrenal gland that was surgically resected. This paper aims to highlight the risk of misdiagnosis in case of cardiac tumors, the hypothetical concept of malignant transformation of a cardiac myxoma, the aggressive course of the extremely rare cardiac intimal sarcoma and the therapeutic modalities available to treat this pathology.
The coronavirus disease 2019 (COVID-19) pandemic has presented unique challenges to international health care systems. Management of the current pandemic puts a huge strain on health care sectors and leads to new strategies conducting by health care systems in countries across the world. In the present article, we review the epidemiologic data, Iranian health care system response, as well as the effects of COVID-19 pandemic on cardiac surgery practice in Iran
The global pandemic of COVID-19 caused by coronavirus has had a profound impact on the delivery of health care in the United States and globally. Boston was among the earliest hit cities in the United States, and within Boston, the Massachusetts General Hospital provided care for more patients with COVID -19 than any other hospital in the region. This necessitated a massive re-allocation of resources and priorities, with near doubling of intensive care bed capacity and a halt in all deferrable surgical cases. During this crisis, the Division of Cardiac Surgery responded in a unified manner, dealing honestly with the necessity to reduce Intensive Care Unit resource utilization, for the benefit of both the institution and our community, by deferring non-emergent cases while also continuing to efficiently care for those patients in urgent or emergent need of surgery. Many of the interventions that we instituted have continued to support teamwork as we adapt to the remarkably fluid changes in resource availability during the recovery phase. We believe that the culture of our division and the structure of our practice facilitated our ability to contribute to the mission of our hospital to support the community in this crisis, and now to its recovery. We describe here the challenge we faced in Boston and some of the details of the structure and function of our division.
This program director survey attempts to determine how coronavirus 2019 (COVID-19) pandemic is impacting current training in cardiothoracic surgery. A transition to virtual didactic sessions may prove beneficial with increasing attendance. On the other hand, decreasing live simulation and case volumes may jeopardize achieving competency in surgical skills.
We present a complication following deployment of the MANTA VCD device following a TAVR procedure which resulted in occlusion of the common femoral artery. This was addressed by ballooning the site from the contralateral side which re-established flow. We believe this is the first report to address this kind of complication and may prove useful as more of the MANTA devices are being used in multiple procedures.
During the first phase of COVID-19 pandemic in Italy, several strategies have been taken to deal with the pandemic outbreak. The Regional Authority of Lombardy remodeled the hospitalization system in order to allocate appropriate resources to treat COVID-19 patients and to identify “Hub/Spoke” hospitals for highly specialized medical activities. The Hubs hospitals were required to guarantee full time evaluation of all patients presenting with cardiovavascular diseases with an independent pathway for patients with suspect or confirmed COVID-19 infection. San Raffaele Hospital was identified as Hub for cardiovascular emergencies and the Vascular Surgery Department was remodeled to face this epidemic situation. Surgical treatment was reserved only to symptomatic, urgent or emergent cases. Large areas of the hospital were simultaneously reorganized to assist COVID-19 patients. During this period, 135 patients were referred to San Raffaele Vascular Surgery Department. COVID-19 was diagnosed in 24 patients and, among them, acute limb ischemia was the most common cause of admission. At this time, the COVID-19 trend is in decline in Italy and the local authorities reorganized the health care system in order to return to normal activities avoiding new escalations of COVID-19 cases. Several strategies have been taken to ensure the safety of the San Raffaele hospital, and maintaining potentially suspected patients with COVID-19 separated from other patients. The aim of this paper is to report the remodeling of the Vascular Surgery Department of San Raffaele Hospital as regards the strategies of preparation, escalation, de-escalation and return to normal activities during the COVID-19 pandemic.
Background: Fibrosa layer stripping (FLS) technique is a new approach to remove calcified aortic valve. In this study, we aimed to assess the effectiveness of the FLS technique by comparing with the conventional technique in minimally invasive aortic valve replacement (MIAVR). Methods: A prospective, single-center, randomized controlled trial was conducted at Beijing Anzhen Hospital. 70 patients diagnosed with severe calcific aortic stenosis were randomly assigned to undergo FLS (n=35) or conventional (n=35) technique to debride calcified aortic valve. Preoperative profile, procedural parameters, and postoperative outcomes were analyzed. Results: No significant difference was observed in the preoperative profile between two groups. Compared with the conventional technique, the FLS technique had significantly higher indexed effective orifice area and lower mean gradient. Moreover, FLS technique was associated with significantly reduced aortic cross-clamp time (41[38-44] vs 56[51-60] min, p<0.001), cardiopulmonary bypass (CPB) time (63[56-69] vs 81[75-84] min, p<0.001) and operative time (148[141-156] vs 173[169-180] min, p<0.001). Lastly, the length of intensive care unit stay (1.2±0.4 vs 1.5±0.8 days, p=0.041) and hospital stay (5.3±0.6 vs 6.0±1.4 days, p=0.020) was significantly reduced in the FLS group compared with those in the conventional group. Conclusions: FLS technique is effective in removing calcified tissue during MIAVR and is associated with shorter cross-clamp time and CPB time, and better hemodynamic performance than conventional technique.