Background:Multidisciplinary heart team (MHT) evaluation is a class I recommendation for coronary and structural heart disease, yet limited outcomes data exist for high-risk and complex valvular heart disease (VHD) patients referred for surgery. Methods:From June 2021 to August 2022, our institutional MHT-comprising cardiac surgeons, interventional cardiologists, heart failure specialists, advanced imaging specialists, intensivists, and palliative care specialists-evaluated the highest-risk or complex VHD patients. Patient demographics, Society of Thoracic Surgeons Predicted Risk of Mortality scores, initial treatment plans, final team recommendations, and outcomes, including adherence to recommendations, 30-day readmission, and mortality at 30 days, 1 year, and 2 years were analyzed. Results:Among 121 patients, the MHT recommended surgery for 67%, transcatheter intervention for 14%, a hybrid approach for 3%, and medical management (MM) for 17%. Overall adherence to MHT recommendations was 89%. Thirty-day mortality was 7/81 (9%) for surgical patients, 3/17 (18%) for transcatheter, 0/3 for hybrid, and 4/20 (20%) for MM. By 2 years, mortality rose to 17/81 (21%) for surgery, 9/17 (53%) for transcatheter, 1/3 (33%) for hybrid, and 11/20 (55%) for MM. Conclusion:MHT evaluation facilitates individualized treatment strategies by distinguishing patients who may benefit from intervention despite high procedural risk, while sparing those unlikely to benefit.

Objectives: Deep venous thrombosis (DVT) is a known surgical complication that can lead to pulmonary embolism with subsequent morbidity and mortality. The incidence of DVT following coronary artery bypass grafting is unclear. Prophylaxis regimens vary and some guidelines advocate against use of routine chemoprophylaxis in patients at low-moderate risk for venous thromboembolism. We utilized postoperative lower extremity venous ultrasound to determine the incidence of DVT following coronary artery bypass grafting in patients with low- to moderate-risk of venous thromboembolism receiving aggressive postoperative DVT prophylaxis. Methods: This is a single-center, retrospective study of all patients who underwent coronary artery bypass grafting between April 2022 and January 2023. All patients who completed postoperative venous ultrasound of the bilateral lower extremities were initially included. Patients who underwent concurrent valve or aortic surgery, were at high risk of venous thromboembolism, or were receiving anticoagulation therapy for nonvenous thromboembolism indications were excluded. The primary outcome was in-hospital incidence of DVT. Secondary outcomes were rates of mortality, postoperative bleeding, and thromboembolic events from discharge to 30 days postoperatively and from 30 days to 3 months postoperatively. Results: No DVTs were observed in 211 included patients. In hospital, there were 3 significant bleeding events and 1 stroke. Following discharge there were 3 additional bleeding events, 1 death, 1 transient ischemic attack, and 1 pulmonary embolism. Conclusions: We observed a 0% rate of DVT in low- to moderate-risk patients undergoing isolated coronary artery bypass grafting and receiving a comprehensive DVT prophylaxis regimen. In hospital bleeding and other thromboembolic event rates were 2.84% and 0.47% respectively. (JTCVS Open 2024;17:145-51)

Background: Left subclavian artery (LSA) revascularization has been recommended for patients undergoing elective thoracic endovascular aortic repair (TEVAR) with a proximal zone 2 landing requiring coverage of the LSA. The clinical standard of care remains surgical LSA revascularization. However, recently, the feasibility of using branched endografts has been demonstrated. We compared the perioperative and mid-term outcomes of these approaches. Methods: We performed a retrospective review of consecutive patients who underwent TEVAR with a proximal zone 2 landing at a single center from 2014 to 2020. The patients were divided into cohorts for comparison: those who underwent surgical revascularization (SR-TEVAR group) and those who underwent thoracic branched endografting with an investigational device (TBE group). Those patients who did not undergo LSA revascularization were excluded. Perioperative outcomes, including procedural success, death, stroke, limb ischemia, and length of stay, were compared. Kaplan-Meier survival curves were compared using the log-rank test. The cumulative incidence of device-related endoleak (types I and III) and device-related reintervention, accounting for death as a competing hazard, were compared using the Fine-Gray test. Results: A total of 55 patients were included: 31 (56%) in the SR-TEVAR group and 24 (44%) in the TBE group. The pre-operative demographics and comorbidities were similar between the two groups. Procedural success was 100% in both cohorts, with no periprocedural strokes or left upper extremity ischemic events. One operative or 30-day death (TBE, 4.2%; vs SR-TEVAR, 3.2%; P =.99) occurred in each cohort. The total operative time (TBE, 203 +/- 79 minutes; vs SR-TEVAR, 250 +/- 79 minutes; P =.03) and total length of stay (TBE, 5.2 +/- 3.6 days; vs SR-TEVAR, 9.9 +/- 7.2 minutes; P = .004) were both significantly shorter in the TBE group. No difference was found in mid-term survival (log-rank test, P =.50) nor the cumulative incidence of device-related endoleak (Fine-Gray test, P =.51) or reintervention (Fine-Gray test, P =.72). No occlusions of the TBE graft or surgical bypass or transpositions had occurred after a mean follow-up of 28 +/- 16 and 34 +/- 24 months, respectively. Conclusions: TBE can be performed with procedural success rate and safety profile comparable to those of TEVAR with surgical revascularization, with a decreased total length of stay, for patients requiring proximal zone 2 coverage. The midterm outcomes for each approach were also similar. Prospective, randomized comparisons of these techniques are warranted.

Abstract Bentall and valve-sparing root replacement (VSRR) procedures are established treatments for aortic root disease. We present a single-center retrospective analysis comparing outcomes of bioprosthetic Bentall (BB), mechanical Bentall (MB), and VSRR patients from November 2007 to October 2016. Survival analysis was performed to evaluate the composite endpoint of freedom from recurrent aortic insufficiency, reoperation, or death. Of the 170 patients, BB was performed in 36 patients, MB in 63 patients, and VSRR in 71 patients. For BB, MB, and VSRR, the mean age was 63.8, 45.5, and 49.2 years (P < 0.001), respectively. Additionally, significantly more patients in the MB group (n = 32, 50.8%, P < 0.001) than in the BB and VSRR groups had prior cardiac surgeries. Cardiopulmonary bypass time and cross-clamp time were significantly longer in the VSRR group (P = 0.04 and 0.0005, respectively). Despite the complexity of the procedure, VSRR patients had higher combined freedom from death and reoperation than patients in the BB or MB groups. Elective Bentall root replacement is an excellent option for patients with root disease. Patients undergoing Bentall tend to have more severe or emergent cases, making them unlikely candidates for VSRR. VSRR in experienced centers carries equivalent morbidity and mortality and improved survival.

The aim of this study is to investigate whether repairing the tricuspid valve (TV) in patients with mild to moderate tricuspid regurgitation (TR) at the time of mitral valve surgery would improve outcomes compared to isolated mitral valve (MV) surgery. We aimed to anticipate the ongoing CTSN

Background. Surgery for isolated tricuspid valve (TV) disease remains relatively infrequent because of significant patient comorbidities and poor surgical outcomes. This study reviewed the experience with isolated TV surgery in the current era to determine whether outcomes have improved. Methods. From 2007 through 2017, 685 TV operations were performed in a single institution, of which 95 (13.9%) operations were isolated TV surgery. Patients were analyzed for disease origin, risk factors, operative mortality and morbidity, and long-term survival. Results. A total of 95 patients underwent isolated TV surgery, an average of 9 patients per year increasing from an average of 5 per year to 15 per year during the study period. Surgery was reoperative in 41% (38 of 95) of patients, including 11.6% (11 of 95) with prior coronary artery bypass grafting and 29.4% (28 of 95) with prior valve surgery (9 TV, 11 mitral, 2 aortic, 5 mitral and aortic, and 1 mitral and TV). Repair was performed in 71.6% (68 of 95) of patients, and replacement was performed in 28.4% (27 of 95). Operative mortality was 3.2% (3 of 95), with no mortality in the most recent 73 patients over the last 6 years. Stroke occurred in 2.1% (2 of 95) of patients, acute kidney injury requiring dialysis in 5.3% (5 of 95), and the need for new permanent pacemaker in 16.8% (16 of 95). Conclusions. In the current era with careful patient selection and periprocedural management, isolated TV surgery can be performed with lower morbidity and mortality than has traditionally been reported with good long-term survival. These outcomes can also serve as a benchmark for catheter-based TV intervention outcomes. (C) 2019 by The Society of Thoracic Surgeons

The tricuspid valve (TV) is an increased focus of surgery and intervention. We reviewed our current experience with concomitant TV surgery to determine if outcomes have improved From 2007 to 2017, 685 TV operations were performed in a single institution of which 590 were concomitant TV surgery.

Immediate surgery is standard therapy for acute type A aortic dissections (TAAD). Because of its low incidence, many smaller cardiac surgery programs do not routinely perform this procedure because it may negatively affect outcomes. Many high-risk, low-volume (LV) surgical procedures are now preferentially performed in reference centers. We compared the outcomes of surgery for TAAD in high-volume (HV) and LV centers in a single metropolitan area to determine the optimal setting for treatment. Thirty-five of the 37 cardiac surgery programs in the Dallas Ft. Worth metropolitan area participate in a regional consortium to measure outcomes collected in the Society of Thoracic Surgeons Adult Cardiac Database. From January 01, 2008, to December 31, 2014, 29 programs had treated TAAD. Those programs performing at least 100 operations for TAAD were considered HV centers and the others LV. Surgery for TAAD was performed in 672 patients over the 7-year study period with HV centers performing 469 of 672 (70%) of the operations. Despite similar preoperative characteristics, operative mortality was significantly lower in HV versus LV centers (14.1% vs 24.1%; p = 0.001). There was no significant difference in postoperative paralysis rates (2.6% vs 4.5%; p = 0.196), stroke rates (10.7% vs 9.4%; p = 0.623), or 30-day readmission rates (12.1% vs 15.5%; p = 0.292). An improved survival rate in HV centers was maintained over a 5-year follow-up period. Surgery for TAAD in a single large metropolitan area was most commonly performed in HV centers. In conclusion, the treatment of acute thoracic aortic dissection is recommended to be performed in reference centers because of lower early and midterm mortality. (C) 2016 Elsevier Inc. All rights reserved.

The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2015.12.029] on http://www.annalsthoracicsurgery.org.A 37-year-old man, active military, with a known heart murmur presented with new onset dyspnea on significant exertion. Transesophageal echocardiography revealed a subaortic fibrous strand connecting the A2 portion of the mitral valve to the left coronary cusp of the aortic valve, resulting in cusp prolapse and eccentric severe aortic regurgitation (Fig 1, Video). To facilitate surgical excision, transverse aortotomy was performed through an upper partial sternotomy. The abnormal chorda was resected from the underside of the aortic leaflet to the free edge of the mitral leaflet (Fig 2). After the resection, residual prolapse of the left coronary cusp was visualized, so a commissuroplasty was performed to shore up the redundant edges of the leaflet. After aortic closure, two areas of trace-to-mild aortic insufficiency, normal aortic leaflet opening motion, and trace mitral regurgitation were observed by transesophageal echocardiography. The chord was 2.5 cm long and composed of tan-white soft tissue (Fig 3) without necrosis, myxoid degeneration, calcification, or inflammation.Fig 2View Large Image Figure ViewerDownload (PPT)Fig 3View Large Image Figure ViewerDownload (PPT) The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2015.12.029] on http://www.annalsthoracicsurgery.org. Aberrant mitral valve chordae are rare, with fewer than 10 reports of this pathology previously published [1Sherif H.M.F. Banbury M.K. Accessory left atrial chordae: an unusual cause of mitral valve insufficiency.J Thorac Cardiovasc Surg. 2010; 139: e3-e4Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. These chordae typically restrict the anterior leaflet, resulting in either mitral stenosis or regurgitation [2Ivanova V. Anreddy S. Bailey S. Schuett A. Hughes-Doichev R. A case of severe mitral regurgitation due to an unusually long aberrant chorda tendineae straddling the anterior mitral leaflet.Echocardiography. 2012; 29: e156-e158Crossref PubMed Scopus (4) Google Scholar]. To the authors’ knowledge, we report the first case of an aberrant chord causing AR, with resolution after resection. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4MTE5NWRiNDMzNGJjNjA3ZmJlMWY0ZjYxN2U3NmNhOCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MjU1NjE5fQ.VsIsBvq1rb92yZCLXYSG0Lue6UKam65DOw2ZdN3ig2e7ta6Ok-2ejKUg6VanYsbYm2ddAFSXyY2hXOgLCGI2fGnoGgsSwrbFoOHdSomft-ZDoPNP53kR1NXMQZ2ojHYrqUL_D-6W_I9QBYq4qOjWcQFK953UqB2NINMM6NAFeeF6slVItEDrEpK8L2yNG6GgjoBaYNhOezcCbI4e_ujEpSlnPEjOeFSNmmIAkmA1TUWENzSb8aSWEqBbXpZRU-6Iny_tilvuwubzPl5gBiPvQ1kDagDu-UcTJAoA2zf8_0rv_mJkXlAjQw_AICBJl8xf2h_BBMvwHNjUhVfdp5LoJQ Download .mp4 (1.59 MB) Help with .mp4 files Video

Objectives Mini-extracorporeal circulation (MECC) units were developed to reduce postoperative morbidity, transfusion requirements, and inflammation associated with conventional on-pump coronary artery bypass (ONCAB) surgery without the technical demands of the off-pump (OPCAB) technique. We compared perioperative outcomes and inflammatory mediation among OPCAB, MECC, and ONCAB techniques. Methods We prospectively enrolled 102 patients undergoing elective isolated coronary bypass grafting. Perfusion methods were OPCAB (n = 34), MECC (n = 34), and ONCAB (n = 34). Serial blood samples were collected to measure serum inflammatory markers. Results There were no operative deaths or strokes. Total red blood cell (RBC) products used in OPCAB, MECC, and ONCAB patients were 0.676, 1.000, and 1.235 units, respectively. Adjusted (by splined Society of Thoracic Surgeons operative risk score) analysis showed no statistically significant differences in mean RBC product use among the different operative systems (OPCAB vs MECC, P = 0.580; OPCAB vs ONCAB, P = 0.311; MECC vs ONCAB, P = 0.633). Adjusted (by Society of Thoracic Surgeons risk score and baseline level) mean plasma level differences (24 hours postoperative - baseline) of C-reactive protein for OPCAB (117.89; 95% confidence interval [95% CI], 106.23–129.54) and for MECC (124.88; 95% CI, 113.45–136.32) were significantly higher than for ONCAB (98.82; 95% CI, 86.40–111.24). No significant adjusted differences ( P = 0.304) in interleukin-6 level changes were observed. Conclusions Off-pump coronary artery bypass and MECC did not significantly reduce mean total RBC transfusion requirements. Off-pump coronary artery bypass and MECC were associated with greater C-reactive protein elevation than ONCAB, suggestive of an increased inflammatory response to each of these techniques.

BACKGROUND:Femoral artery pseudyoaneurysms are a common complication after femoral access for transcatheter procedures, frequently requiring operative repair. We review the safety and efficacy of a novel nonsurgical method of pseudoaneurysm treatmentMETHODS:From June 1998 to November 2001, a total of 47 femoral artery pseudoaneurysms in 46 patients were treated by bedside ultrasound-guided injection of dilute topical thrombin. All pseudoaneurysms occurred after femoral access for transcatheter procedures, and were diagnosed clinically and confirmed with ultrasound imaging. Clinical follow-up was performed and included ultrasound (2 hours to 1 month) in 64.4% of patients, including any patient with a symptomatic or clinical change.RESULTS:Pseudoaneurysms ranged in size from 1.5 to 4.5 cm. Of 47 pseudoaneurysms, 45 were successfully obliterated on the initial injection. After successful obliteration of pseudoaneurysm, 1 patient sustained thrombosis of the tibioperoneal trunk that required surgical embolectomy, yielding a complication rate of 2%. Four pseudoaneurysms recurred after initially successful obliteration. In 1 of these cases, the patient was taken directly to surgery, and 3 were successfully treated with repeat injection, for an overall success rate of 93.6%.CONCLUSIONS:Obliteration of femoral artery pseudoaneurysm by injection is safe and effective, and may be associated with decreased morbidity. Recurrent pseudoaneurysms may be safely reinjected, with a high success rate.