HomeCirculation: Arrhythmia and ElectrophysiologyAhead of PrintCardiac Perforation During High-Power Radiofrequency Ablation of the Left Lateral Ridge Using QDOT MICRO No AccessLetterRequest AccessAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessLetterRequest AccessCardiac Perforation During High-Power Radiofrequency Ablation of the Left Lateral Ridge Using QDOT MICRO Carola Gianni, Matthew Dare, Javier E. Sanchez, Amin Al-Ahmad, Jason D. Zagrodzky, G. Joseph Gallinghouse, J. David Burkhardt, Robert C. Neely and Andrea Natale Carola GianniCarola Gianni Correspondence to: Carola Gianni, MD, PhD, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Ste 720, Austin, TX 78705. Email E-mail Address: [email protected] https://orcid.org/0000-0002-8174-7207 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Matthew DareMatthew Dare Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Javier E. SanchezJavier E. Sanchez https://orcid.org/0000-0002-4488-9863 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Amin Al-AhmadAmin Al-Ahmad https://orcid.org/0000-0002-8547-025X Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Jason D. ZagrodzkyJason D. Zagrodzky https://orcid.org/0000-0002-0078-5309 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , G. Joseph GallinghouseG. Joseph Gallinghouse https://orcid.org/0000-0002-6233-9355 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , J. David BurkhardtJ. David Burkhardt https://orcid.org/0000-0003-1925-5241 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Robert C. NeelyRobert C. Neely Cardiothoracic and Vascular Surgeons, Austin, TX (R.C.N.). and Andrea NataleAndrea Natale https://orcid.org/0000-0002-5487-0728 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). Interventional Electrophysiology, Scripps Clinic, La Jolla, CA (A.N.). MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH (A.N.). Originally published17 Apr 2024https://doi.org/10.1161/CIRCEP.123.012643Circulation: Arrhythmia and Electrophysiology. 2024;0:e012643FootnotesFor Sources of Funding and Disclosures, see page XXX.Correspondence to: Carola Gianni, MD, PhD, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Ste 720, Austin, TX 78705. Email carola.gianni@gmail.com eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2024 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.123.012643PMID: 38629294 Originally publishedApril 17, 2024 Keywordsatrial fibrillationcatheter ablationintraoperative complicationspericardial effusionthoracic surgeryPDF download Advertisement SubjectsAtrial FibrillationCatheter Ablation and Implantable Cardioverter-Defibrillator

Despite recent public policy initiatives, rheumatic heart disease (RHD) remains a major source of morbidity worldwide. Rheumatic heart disease occurs as a sequela of Streptococcus pyogenes (group A streptococcal [GAS]) infection in patients with genetic susceptibility. Strategies for prevention of RHD or progression of RHD include prevention of GAS infection with community initiatives, effective treatment of GAS infection, and secondary prophylaxis with intramuscular penicillin. The cardiac surgical community has attempted to improve the availability of surgery in RHD-endemic areas with some success, and operative techniques and outcomes of valve repair continue to improve, potentially offering patients a safer, more durable operation. Innovation offers hope for a more scalable solution with improved biomaterials and transcatheter delivery technology; however, cost remains a barrier.

INTRODUCTION:Transvenous lead extraction (TLE), while mostly a safe procedure, has risk of serious periprocedural complications. As such, overnight hospitalization remains a routine practice. In our center, we routinely discharge patients on the same day following an uncomplicated TLE. METHODS:This is a retrospective study of 265 consecutive patients who underwent uncomplicated TLE in our center between 2019 and 2021. Same-day discharge (SDD) patients are compared with those who stayed at least overnight for observation after the TLE procedure (non-SDD group). To assess the safety of an SDD strategy after uncomplicated TLE, the main study endpoint was to compare the rate of major procedure-related complications at 1-, 7-, and 30-days. To identify the factors influencing the operator's decision to discharge the patient on the same day, the secondary endpoint was to analyze clinical and procedural predictors of SDD. RESULTS:A total of 153 patients were discharged the same day after uncomplicated TLE (SDD), while 112 stayed at least overnight after the procedure (non-SDD). There was no significant difference in major procedure-related complications at 1-day (SDD 0% vs. non-SDD 1.8%, p value = ns), while patients in the SDD group had a lower rate of 7- and 30-day complications when compared with those in the non-SDD group (2.1% vs. 8.2%, p value = .0308; and 3.5% vs. 16%, p value = .0049, respectively). Noninfectious indication for TLE (OR 16.1, 95% confidence interval [CI] 4.29-77.6) and procedure end time before 12:00 (OR 2.82, 95% CI 1.11-7.27) were the only independent predictors of SDD. CONCLUSION:SDD discharge following uncomplicated TLE in selected patients (i.e., those without device infection and when the TLE procedure is completed in the morning) is feasible and safe.

Introduction: Transvenous lead extraction (TLE), while mostly a safe procedure, has risk of serious periprocedural complications. As such, overnight hospitalization remains a routine practice. Same-day discharge (SDD) may be considered in uncomplicated TLE. Herein, we sought evaluate the safety of SDD. Methods: This is a retrospective analysis of 89 consecutive pts who underwent TLE in our center from January through December 2020. SDD patients were compared those with longer hospital stay (non-SDD) with respect to clinical and procedural characteristics. The safety endpoint was incidence of re-hospitalization/death at 30-days. Results: 51 patients had SDD after TLE and 38 had non-SDD (median length of stay, 2 days IQR 1-5). 38% were female, with a mean age of 67±14 years and BMI of 27.9±7.4 Kg/m 2 . The main indication for TLE was malfunction for SDD vs infection for non-SDD (figure). Clinical characteristics were comparable, with a trend for a higher rate of co-morbidities predisposing to infection for non-SDD (figure). As expected, SDD patients had fewer leads to extract (1.5±0.6 vs 2.1±1.1; p=0.003), albeit with a similar dwelling time (105±65 months vs 114±70 months), and shorter procedural times (90±47 min vs 125±87 min; p=0.01). Of note, laser was used as an adjunct extraction tool at a comparable rate (75% vs 76%). There was no significant difference in the safety endpoint (8% SDD vs 3% non-SDD; p=ns), with 1 post-procedural death (pulmonary embolism) in the non-SDD group, and 4 re-hospitalizations in the SDD group: 1 for evacuation of a pocket hematoma, 1 for drainage of a late symptomatic pericardial effusion secondary to pericarditis, 1 for lead revision. Conclusions: SDD discharge following uncomplicated TLE in selected patients is feasible, with an acceptable safety profile with respect to 30-days clinical outcomes.

OBJECTIVESBicuspid aortic valve (BAV) is the most common congenital valvular abnormality and frequently presents with accelerated calcific aortic valve disease, requiring aortic valve replacement (AVR) and thoracic aortic aneurysm and dissection. Supporting evidence for Association Guidelines of aortic dimensions for aortic resection is sparse. We sought to determine whether concurrent repair of dilated or aneurysmal aortic disease during AVR in patients with BAV substantially improves morbidity and mortality outcomes.METHODSMortality and reoperation outcomes of 1301 adults with BAV and dilated aorta undergoing AVR-only surgery were compared to patients undergoing AVR with aortic resection (AVR-AR) using Cox proportional hazards modelling and patient matching.RESULTSClinically important differences in patient characteristics, aortic valve function and aortic dimensions were identified between cohorts. Event rates were low, with rates of reoperation and death within 1 year of only 1.8% and 5.4%, respectively, and no aortic dissection observed during follow-up. There were no significant differences in reoperation or mortality outcomes between the AVR-only and AVR-AR cohorts. Age, aortic dimension or a combination thereof was not associated with better or worse outcomes after each AVR-AR compared with AVR.CONCLUSIONSWe conclude AVR-only and AVR-AR surgery have low morbidity and mortality and have utility over a wide range of age and aortic sizes. Our results do not provide support for the 45-mm aortic dimension recommended in the current guidelines for aortic resection while performing AVR or any other specific dimension.

BACKGROUND Patient comorbidities play a pivotal role in the surgical outcomes of reoperative aortic valve replacement (re-AVR). Low left ventricular ejection fraction (LVEF) and renal insufficiency (Cr >2 mg/dL) are known independent surgical risk factors. Improved preoperative risk assessment can help determine the best therapeutic approach. We hypothesize that re-AVR patients with low LVEF and concomitant renal insufficiency have a prohibitive surgical risk and may benefit from transcatheter AVR (TAVR). METHODS From January 2002 to March 2013, we reviewed 232 patients who underwent isolated re-AVR. Patients older than 80 years were excluded to adjust for unobserved frailty. We identified 37 patients with a ≤35% LVEF (low ejection fraction group-LEF) and 195 patients with >35% LVEF (High ejection fraction group-HEF). RESULTS The mean age was 68.4±11.5 years and there were more females (86.5% versus 64.1%, P=0.007) in the LEF group. The prevalence of renal insufficiency was higher in LEF patients (27% versus 5.6%, P=0.001). Higher operative mortality (13.5% versus 3.1%, P=0.018) was observed in the LEF group. Stroke rates were similar in both groups (8.1% versus 4.1%, P=0.39). Unadjusted cumulative survival was significantly lower in LEF patients (6.6 years, 95% CI: 5.2-8.0, versus 9.7 years, 95% CI: 8.9-10.4, P=0.024). In patients without renal insufficiency, LEF and HEF had similar survival (8.3 years, 95% CI: 7.1-9.5, versus 9.9 years, 95% CI: 9.1-10.6, P=0.90). Contrarily, in patients with renal insufficiency, LEF led to a significantly lower survival (1.1 years, 95% CI: 0.1-2.0, versus 4.8 years, 95% CI: 2.2-7.3, P=0.050). Adjusted survival analysis revealed elevations in baseline creatinine (HR =4.28, P<0.001) and LEF (HR =5.33, P=0.041) as significant predictors of long-term survival, with a significant interaction between these comorbidities (HR =7.28, P<0.001). CONCLUSIONS In re-AVR patients, low LVEF (≤35%) is associated with increased operative mortality. Concomitant renal insufficiency in these patients results in a prohibitively low cumulative survival. These reoperative surgical outcomes should warrant expanding the role of TAVR for reoperative patients with LEF and renal impairment.

Although donors with well-functioning bicuspid aortic valves (BAV) are not a contraindication for transplantation, BAV patients are at risk for long-term aortopathy and valve dysfunction. We report a case of a patient status-post heart transplant 13 years ago who presented to our institution with a BAV and severe aortic regurgitation associated with an aortic root aneurysm and underwent aortic root replacement.

BACKGROUND:Isolated tricuspid valve (ITV) operations are infrequent and the decision to operate is controversial. We report a series of ITV operations to outline the current disease status requiring this uncommon procedure with an emphasis on the results of tricuspid valve repair (TVr) versus replacement (TVR).METHODS:Using our prospective cardiac surgery database, 57 patients who underwent ITV operations between 01/02-03/14 were identified. Median follow up time was 3.5 years [interquartile range (IQR), 0.8-6.7 years].RESULTS:Fifty-seven patients underwent ITV surgery with a mean age of 54.4±14.9 yrs and 61% were women. Baseline characteristics were similar between patients who underwent TVr (n=18) or TVR (n=39). The etiologies of TV dysfunction were: ITV endocarditis 14/57 (25%), persistent TV regurgitation after left-sided valve surgery in 12/57 (21%), traumatic biopsies and iatrogenic injury from pacing leads in 11/57 (19%), orthotopic heart transplant 9/57 (16%), carcinoid syndrome 3/57 (5%), congenital 2/57 (5%) and idiopathic 5/57 (9%). Overall, 32/57 (56%) patients had prior heart surgery; of which 10/32 (31%) were TV procedures. Bioprosthetic prostheses were used in 34/39 (87%) patients. Of those who had repair, 11/18 (61%) had ring annuloplasty, 3/18 (17%) bicuspidization, and 3/18 (17%) De Vega annuloplasty and one had vegetectomy. Operative mortality was 5.1% (n=2) and 16.7% (n=3) for TVR and TVr groups, respectively (P=0.32), with an overall mortality rate of 8.6%. Postoperative complications included new onset renal failure in 6/39 (15%) of TVr and 2/18 (11%) of TVR (P=0.71) and there were no strokes. Overall survival rates and degree of residual RV dysfunction were similar for the two groups (both P=0.3). Five-year survival was 77% and 84% for TVr and TVR respectively (P=0.52). There was no difference in rates of recurrent tricuspid regurgitation for TVr and TVR (35.7% vs. 23.5%, respectively, P=0.4).CONCLUSIONS:ITV surgery is associated with improved but still relatively high operative mortality. Mid-term outcomes for TVr and TVR are similar with regards to postoperative complications, survival, and freedom from recurrent tricuspid regurgitation.

Background. The current study assesses outcomes and risk factors for aortic valve replacement (AVR) for aortic regurgitation (AR) in the setting of markedly reduced left ventricular (LV) function compared with moderately reduced LV function and preserved LV function.Methods. Between January 2002 and June 2013, 485 consecutive patients underwent AVR for severe AR. Overall, 37 of 485 patients (8%) had an LV ejection fraction (EF) less than or equal to 35% (low EF) with median of 30%; 141 of 485 patients (27%) had an LVEF of 36% to 50% (moderate) with median of 45%, and 307 of 485 patients (65%) had an LVEF greater than 50% (preserved) with median of 60%.Results. Preoperative characteristics were similar across groups, except patients with low EF were older (67.4 +/- 12.1 years versus moderate [58.6 +/- 15.0 years], p = 0.003 versus preserved [56.9 +/- 14.3 years], p = 0.001), more often had reoperations (35.1% versus preserved 19.9%, p = 0.054), and had more concomitant coronary artery bypass grafts 37.6% versus preserved 14.3%, p = 0.001). Operative mortality for the entire cohort was 1.9% (9 or 485) and was similar across groups, 0% in the low EF group, 2.1% (3 of 141) in the moderate group, and 2.0% (6 of 307) in the preserved group (all p > 0.5). Cox proportional hazard modeling indicated that age (hazard ratio [HR] 1.061, p <= 0.001), preoperative creatinine (HR 1.478, p <= 0.014), history of atrial fibrillation (HR 1.920, p = 0.095), and New York Heart Association class III/ IV (HR 2.127, p = 0.004) predicted survival. At median follow-up of 26 months, in the low EF group, the mean LVEF at follow-up was 49.5% +/- 10.2% versus baseline 30% +/- 4.6% (p <= 0.001).Conclusions. In this series, patients with markedly reduced LV function (LVEF <= 35%) had similar postoperative outcomes and survival as patients with moderate LV dysfunction or preserved LV function. (C) 2016 by The Society of Thoracic Surgeons

The 4th All-Africa Workshop on Acute Rheumatic Fever and Rheumatic Heart Disease (RHD) was held in Addis Ababa from March 4-6, 2016, hosted by the Pan-African Society of Cardiology (PASCAR) and the African Union Commission (AUC). This was a conference of expert cardiologists and cardiac surgeons who are leading RHD efforts, and included delegates from 22 African countries (Figure 1). There were also representatives from major international stakeholders, such as the World Health Organization (WHO), the World Heart Federation (WHF), as well as the philanthropic arms of the Novartis and Medtronic, both of which have active programs targeting RHD.

Congenital pulmonary airway malformation (CPAM) is a developmental abnormality of the lung, which results from an abnormality of branching during fetal development of the lung. We report the case of an 18 year-old woman who developed Kirsten rat sarcoma virus (KRAS) mutation positive mucinous adenocarcinoma of the lung (AC) in association with mixed CPAM type 1 and 2. This case is unique as KRAS mutation positive AC is present in a setting of both CPAM 1 and 2 in the same lesion.

OBJECTIVES:Del Nido cardioplegia in adult cardiac surgery has not been studied although it has been in common use as a "single" dose cardioplegia in pediatric heart surgery. We retrospectively assessed the short-term (in-hospital) clinical outcomes of patients undergoing aortic valve replacement (AVR) using del Nido cardioplegia solution, comparing it to conventional multi-dose whole blood cardioplegia.METHODS:We switched our cardioplegia protocol from conventional whole blood cardioplegia exclusively to del Nido solution in May 2011. In 2011, 240 consecutive patients underwent isolated AVR. One hundred and seventy-eight of them were operated on with the use of del Nido cardioplegia (del Nido group) and whole blood cardioplegia (conventional group) was used in the other 62 patients. Isolated AVR was chosen as a cohort because of its relative simplicity and the similarity of surgical techniques among surgeons. Propensity-score matching identified 54 matched pairs for analysis.RESULTS:The retrograde cardioplegia technique was used in 19 cases (35.2%) in the del Nido group and 52 cases (96.3%) in the conventional group (p<0.001). Mean cardiopulmonary bypass time and mean aortic cross-clamp time were significantly shorter in the del Nido group compared to the conventional group: 71 ± 16 min vs. 84 ± 28 min (p<0.01), 52 ± 14 min vs. 60 ± 16 min (p<0.01), respectively. Postoperative inotropic support was required in 11 patients (20.4 %) in the del Nido group and 13 patients (24.1 %) in the conventional group (p=0.82) with no statistical difference. No patient required a postoperative intra-aortic balloon pump and in-hospital mortality was 0% in both groups. There was no significant difference in postoperative complications between the two groups.CONCLUSIONS:Short-term outcomes in adult cardiac surgery using del Nido solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. The del Nido cardioplegia technique was associated with shortened cross-clamp times and less frequent utilization of the retrograde cardioplegia delivery technique.

BACKGROUND AND AIM OF THE STUDY:The advantages of minimally invasive aortic valve replacement (AVR) are well documented, but whether the benefits extend to subsequent reoperative aortic valve surgery and beyond is unknown. The study aim was to compare in-hospital outcomes and long-term survival following reoperative AVR between patients who had previous undergone either minimally invasive AVR (mini-AVR) or full sternotomy AVR (sAVR).METHODS:All reoperative, isolated AVRs performed between July 1997 and September 2013 at the authors' institution, with or without non-complex aortic surgery, were identified. Patients were excluded if AVR was not isolated, had occurred prior to July 1997, or if the initial AVR was performed before the patient was aged 18 years. All reoperations were performed through a full sternotomy. The main outcomes of interest were operative results and long-term survival.RESULTS:A total of 101 patients was identified, of which 34 had undergone previous mini-AVR and 67 previous sAVR. The time from the previous AVR was similar in both groups (median 7.6 years overall). Of previous valve implants, 57 were bioprostheses and 44 mechanical; structural valve degeneration was the most common indication for surgery (43/101). Mini-AVR and sAVR patients did not differ significantly with regards to patient demographics and preoperative risk factors. A strong trend towards shorter skin-to-skin operative times was observed for mini-AVR (330 min versus 356 min; p = 0.053). Postoperatively, mini-AVR patients had a shorter ventilation time (5.7 h versus 8.4 h; p = 0.005), intensive care unit stay (37 h versus 63 h; p ≤ 0.001) and hospital length of stay (6.5 days versus 8.0 days; p = 0.038). There was one operative mortality in the sAVR, and none in the mini-AVR group. Mid-term survival at one and five years for mini-AVR was 100% (95% CI 100-100) and 100% (95% CI 100-100), and for sAVR was 93.9% (95% CI 88.2-99.7) and 85.0% (95% CI 75.1-94.9), respectively (p = 0.041).CONCLUSION:Mini-AVR confers benefits during subsequent reoperative AVR, with shorter hospital stays and improved long-term survival. These findings suggest that mini-AVR should be considered for patients at risk for aortic valve reoperation, and describes a previously unreported advantage of this well-established technique.

OBJECTIVES Aortic valve replacement (AVR) in patients with severely atherosclerotic aortas (porcelain aorta) presents a significant technical challenge. Two strategies are deep hypothermic circulatory arrest (DHCA) during conventional surgery and transcatheter aortic valve replacement (TAVR). The aim of this study was to examine the outcomes in patients who underwent DHCA for AVR with a porcelain aorta to identify whether older patients are more suitable for TAVR. METHODS Between October 2004 and December 2012, 122 patients underwent AVR using DHCA for atherosclerotic aorta. Patients with concomitant valve surgery were excluded. Overall, 63.9% (78/122) were of age <80 (non-octogenarian group, NOG) and 36.1% (44/122) were >80 (octogenarian group, OG). Of the total cohort, 62.3% (76/122) had concomitant coronary artery bypass graft surgery. RESULTS The mean age for the whole cohort was 75.7 ± 8.5 years; 70.2 ± 8.1 years for the NOG and 83.4 ± 2.6 years for the OG (P = 0.001). The OG had a higher rate of preoperative renal failure (20.5%, 9/44 vs 7.7%, 6/78, P = 0.048) and trends towards a greater history of cerebrovascular disease (9.1%, 4/44 vs 1.3%, 1/78, P = 0.056), but fewer reoperations (6.8%, 3/44 vs 19.2%, 15/78, P = 0.069). Cardiopulmonary bypass time, aortic cross-clamp time and circulatory arrest time were similar between the two groups. Postoperative complication rates were similar except for permanent stroke (OG 18.2%, 8/44 vs NOG 6.4%, 5/78, P = 0.065). The overall operative mortality rate was 8.2% (10/122); however, the OG had significantly higher operative mortality compared with the NOG (15.9%, 7/44 vs 3.8%, 3/78, P = 0.035). One- and 5-year survival rates were 88.9 and 79.3% for the NOG versus 75.0 and 65.9% for the OG (P = 0.027), respectively. CONCLUSIONS Postoperative neurological events and operative mortality were, respectively, 3- and 4-fold higher in octogenarians undergoing AVR using DHCA. Such patients may represent suitable candidates for TAVR if favourable outcomes are demonstrated in patients with atherosclerotic aortas. Surgical AVR remains the standard treatment option with excellent outcomes for patients <80 years old with unclampable aortas.

Background. Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period.Methods. Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients.Results. Mean age was 59 +/- 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p=0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p=0.018).Conclusions. This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated. (C) 2015 by The Society of Thoracic Surgeons

BACKGROUNDMinimally invasive aortic valve surgery (mini AVR) is a safe and effective treatment option at many hospital centers, but there has not been widespread adoption of the procedure. Critics of mini AVR have called for additional evidence with direct comparison to aortic valve replacement (AVR) via full sternotomy (FS).METHODSOur mini AVR approach is through a hemi-sternotomy (HS). We performed a propensity-score matched analysis of all patients undergoing isolated AVR via FS or HS at our institution since 2002, resulting in 552 matched pairs. Baseline characteristics were similar. Operative characteristics, transfusion rates, in-hospital outcomes as well as short and long term survival were compared between groups.RESULTSMedian cardiopulmonary bypass and cross clamp times were shorter in the HS group: 106 minutes [inter-quartile ranges (IQR) 87-135] vs. 124 minutes (IQR 90-169), P≤0.001, and 76 minutes (IQR 63-97) vs. 80 minutes (IQR 62-114), P≤0.005, respectively. HS patients had shorter ventilation times (median 5.7 hours, IQR 3.5-10.3 vs. 6.3 hours, IQR 3.9-11.2, P≤0.022), shorter intensive care unit stay (median 42 hours, IQR 24-71 vs. 45 hours, IQR 24-87, P≤0.039), and shorter hospital length of stay (median 6 days, IQR 5-8 vs. 7 days, IQR 5-10, P≤0.001) compared with the FS group. Intraoperative transfusions were more common in FS group: 27.9% vs. 20.0%, P≤0.003. No differences were seen in short or long term survival, or time to aortic valve re-intervention.CONCLUSIONSOur study confirms the clinical benefits of minimally invasive AVR via HS, which includes decreased transfusion requirements, ventilation times, intensive care unit and hospital length of stay without compromising short and long term survival compared to conventional AVR via FS.

Surgical repair techniques for myxomatous mitral regurgitation have evolved over time, with multiple different methods in current use. The loop neochord technique provides a versatile and reproducible method that can be used for anterior, posterior, or bileaflet prolapse, as well as Barlow’s disease. Preoperative planning and careful intraoperative valvular assessment are used to determine the appropriate loop length. Prefabricated commercial loops are available, but loops can also be created at the time of operation with polytetrafluroethylene 4-0 sutures and pledgets. We describe specific leaflet and subvalvular landmarks and suture placement techniques to ensure an accurate and durable mitral valve repair. Although these principles can be applied via a full sternotomy, we illustrate our preferred approach using the loop technique via a right minithoracotomy and femoral cardiopulmonary bypass. Surgical repair techniques for myxomatous mitral regurgitation have evolved over time, with multiple different methods in current use. The loop neochord technique provides a versatile and reproducible method that can be used for anterior, posterior, or bileaflet prolapse, as well as Barlow’s disease. Preoperative planning and careful intraoperative valvular assessment are used to determine the appropriate loop length. Prefabricated commercial loops are available, but loops can also be created at the time of operation with polytetrafluroethylene 4-0 sutures and pledgets. We describe specific leaflet and subvalvular landmarks and suture placement techniques to ensure an accurate and durable mitral valve repair. Although these principles can be applied via a full sternotomy, we illustrate our preferred approach using the loop technique via a right minithoracotomy and femoral cardiopulmonary bypass.

Del Nido cardioplegia, a crystalloid‐based solution with lidocaine as a key element, is given as a single dose and has been used successfully in congenital cardiac surgery.