Background: Dysphagia following cardiac surgery is common and associated with adverse outcomes. Among patients receiving left ventricular assist device (LVAD), we evaluated the impact of fiberoptic endoscopic evaluation of swallowing (FEES) on outcomes. Methods: A single-center pilot study was conducted in adults (≥18 years of age) undergoing durable LVAD (February 2019-January 2020). Six patients were prospectively enrolled, evaluated, and underwent FEES within 72 hours of extubation—they were compared to 12 control patients. Demographic, surgical, and postoperative outcomes were collected. Unpaired two-sided t-tests and Fisher’s Exact tests were performed. Results: Baseline characteristics were similar between groups. Intraoperative criteria including duration of transesophageal echo (314 ± 86 min) and surgery (301 ± 74 min) did not differ. Mean time of intubation was comparable (57.3 vs. 68.7 hours, p=0.77). In the entire cohort, 30-day, 1-year, 2-year, and 3-year mortality were 0%, 5.6%, 5.6%, and 16.7%, respectively. Sixty-seven percent of the patients that underwent FEES had inefficient swallowing function. The FEES group trended to a shorter hospital length of stay (LOS) (29.1 vs. 46.6 days, p=0.098), post-implantation LOS (25.3 vs 30.7 days, p=0.46), and lower incidence of postoperative pneumonia (16.7% vs. 50%, p=0.32) and sepsis (0% vs. 33.3%, p=0.25). Conclusions: FEES did not impact 30-day, 1-year, 2-year, or 3-year mortality. Patients who underwent FEES trended toward shorter LOS, and lower postoperative pneumonia and sepsis rates, though not statistically significant. A higher incidence of dysphagia among patients undergoing FEES despite comparable baseline risk factors with controls suggests FEES may detect subclinical dysphagia.
Objective: Valve-sparing root replacement is commonly used for management of aortic root aneurysms in elective setting, but its technical complexity hinders its broader adoption for acute Type-A Aortic Dissection (ATAAD). The Florida Sleeve (FS) procedure is a simplified form of valve sparing aortic root reconstruction that does not require coronary reimplantation. Here, we present our outcomes of the Florida Sleeve (FS) repair in patients with dilated roots in the setting of an ATAAD. Methods: We retrospectively reviewed 24 consecutive patients (2002-2018) treated with FS procedure for ATAAD. Demographic, operative, and postoperative outcomes were queried from our institutional database. Long term follow-up was obtained from clinic visits for local patients, and with telephone and telehealth measures otherwise. Results: Mean age was 49 ± 14 years with 19 (79%) males. Marfan syndrome was present in 4 (16.7%) patients and 14 (58.3) had ≥2+ aortic insufficiency (AI). Nine (37.2%) had preoperative mal-perfusion or shock. The FS was combined with hemi-arch replacement in 15 (62.5%) patients and a zone-2 arch replacement in 9 (37.5%) patients. There were 2 (8.3%) early postoperative mortalities. Median follow-up period was 46 months (range; 0.3-146). The median survival of the entire cohort was 143.4 months. One patient (4.2%) required redo aortic valve replacement for unrelated aortic valve endocarditis at 30 months postoperatively. Conclusion: FS is simplified and reproducible valve-sparing root repair. In appropriate patients, it can be applied safely in acute Stanford type-A aortic dissection with excellent early and long-term results.
Background: Monitored Anesthesia Care (MAC) has been increasingly used in lieu of general anesthesia (GA) for transcatheter aortic valve replacement (TAVR). We sought to compare outcomes and in-hospital costs between MAC and GA for TAVR at a single center Veterans Affairs Medical Center. Methods: A single-center retrospective review of 349 patients who underwent TAVR (MAC, n = 244 vs. GA, n = 105) from January 2014 to December 2019 was performed. Baseline patient characteristics, operating room (OR) time, intensive care unit (ICU) length of stay (LOS) and cost, total LOS, hospital cost, total cost, and complication rates were collected. Propensity matching was performed and resulted in 83 matched pairs. Results: In the unmatched TAVR cohort, MAC TAVR was associated with reduced OR time (146 vs. 198 minutes, P < .0001), ICU LOS (1.4 vs. 1.8 days, P < 0.0001), total hospital LOS (3.4 vs. 5.4 days, P < .0001), and lower index total cost ($81,3000 vs. $85,400, P = .010). After propensity matching, MAC TAVR patients had reduced OR time (146 vs. 196 minutes, P < 0.05), ICU LOS (1.2 vs. 1.7 days, P = .006), total LOS (3.5 vs. 5.1 days, P = .001), and 180-day mortality (2.4% vs. 12%, P < 0.03). There was no difference in total hospitalization cost or total cost. Conclusions: In propensity matched groups, TAVR utilizing MAC is associated with improved OR time efficiency, decreased LOS, and a reduction in 180-day mortality, but no significant difference in cost.
A kyphotic gentleman with chronic obstructive pulmonary disease and Marfan syndrome whose history was significant for thoracoabdominal aortic replacement secondary contained rupture, presented with chest pain and an acute DeBakey type I aortic dissection. In this anatomically challenging total arch replacement, Cor-Knot fastener was employed without short-term or long-term complications.
LS is a 39-year-old woman with systolic heart failure secondary to viral myocarditis (EF 10-15%). She was transitioned from IABP support to LVAD. Five weeks postoperatively she experienced progressive low flow alarms and underwent pericardial release via left mini-thoracotomy. Flows immediately improved postoperatively.