The United Network for Organ Sharing (UNOS) heart transplant allocation policy was changed in 2018. This study examines the impact of the change in UNOS heart transplant allocation policy on the use of temporary mechanical circulatory support (MCS) devices and post-transplant survival.The analysis included a total of 26,481 patients listed and transplanted between January 2013 and June 2022. The results showed a decrease in waiting time for transplant after the policy change, indicating a successful reduction in waitlist time for high-priority status patients. However, the length of hospital stays from transplant to discharge increased following the policy change. The study also found an increase in the frequency of ECMO and IABP use both at the time of listing and at the time of transplant following the policy change.Cumulative patient and graft survival at 1000 days decreased following the policy change (86.1 per cent versus 83.7 per cent at 1000 days, p = 0.002). However, the survival curves showed similar survival trends in the first 2 years, with late divergence in survival occurring after 2 years.In conclusion the latest UNOS heart transplant allocation policy change led to a decrease in waiting times and an increase in the use of temporary MCS devices. There was a decrease in cummulative survival at 1000 days following the policy change.

Purpose: To analyze both the allocation of heart transplants in patients based on blood type and whether durable VADs alter said distribution. Methods: Data was gathered from the Organ Procurement & Transplantation Network on blood type, status of patients at time of transplant, and if VAD was present at time of transplant nationally and for Region 5 (R5) in 2021. The percentage of each blood type for all status for all transplants and R5 were calculated, as well as the relative transplantation rates for status 4 VADS. Results: Table one shows the distribution of heart transplants by blood type for all transplants nationally, all transplants in R5, all transplants with status 4 VADs, and R5 with status 4 VADs. R5 had an increase in the percentage of status 4 VADs patients transplanted for blood types A and B and a decrease in the percentage of blood type O in comparison to all transplants that occurred in that area. Nationally all transplants and status 4 VAD patients with O and A blood type were transplanted less than the national blood type distribution. R5 transplanted more O patients overall, but less status 4 VAD patients. The opposite was true for A patients in R5. Both nationally and R5, blood type B was transplanted more frequently than the national blood type distribution. Conclusions: Blood type may matter for patients with durable VADs who are eligible for heart transplantation. VAD patients with certain blood types are more or less likely to receive a transplant than patients without a VAD. Both nationally and in R5, blood type O patients are less frequently transplanted with a VAD than without a VAD. On the other hand VAD patients with blood types A and B tend to have more transplants than patients without a VAD. Given a patient’s clinical status and end-goal of cardiac transplantation, it may be more or less beneficial to have a VAD as a bridge to transplant depending on their blood type.

INTRODUCTION:In patients undergoing high-risk cardiac surgery, the uncertainty of outcome may complicate the decision process to intervene. To augment decision-making, a machine learning approach was used to determine weighted personalized factors contributing to mortality.METHODS:American College of Surgeons National Surgical Quality Improvement Program was queried for cardiac surgery patients with predicted mortality ≥10% between 2012 and 2019. Multiple machine learning models were investigated, with significant predictors ultimately used in gradient boosting machine (GBM) modeling. GBM-trained data were then used for local interpretable model-agnostic explanations (LIME) modeling to provide individual patient-specific mortality prediction.RESULTS:A total of 194 patient deaths among 1291 high-risk cardiac surgeries were included. GBM performance was superior to other model approaches. The top five factors contributing to mortality in LIME modeling were preoperative dialysis, emergent cases, Hispanic ethnicity, steroid use, and ventilator dependence. LIME results individualized patient factors with model probability and explanation of fit.CONCLUSIONS:The application of machine learning techniques provides individualized predicted mortality and identifies contributing factors in high-risk cardiac surgery. Employment of this modeling to the Society of Thoracic Surgeons database may provide individualized risk factors contributing to mortality.

INTRODUCTION:The axillary artery is a reliable inflow vessel when addressing pathology of the aortic root and aortic arch that may preclude standard central cannulation strategies. This narrative review examines the use of the axillary artery in cardiac surgery. Anatomy, indications for use, cannulation strategies, and potential complications will be discussed.METHODS:A comprehensive review of the current literature was performed using PubMed, Cochrane Review, and authoritative committee guidelines. A narrative review incorporating current available evidence was undertaken.COMMENT:Use of the axillary artery in select cardiac surgical cases is reliable, reproducible, and may be preferable in certain cases involving ascending aortic pathology, reoperative surgery, porcelain aorta, access for transcatheter valve therapies, and peripheral mechanical circulatory support.

Central MessagePatients who undergo tricuspid valvectomy may develop symptoms of right-sided heart failure and require operative reintervention with valve replacement.See Commentary on page 68. Patients who undergo tricuspid valvectomy may develop symptoms of right-sided heart failure and require operative reintervention with valve replacement. See Commentary on page 68. The incidence of tricuspid valve infective endocarditis secondary to intravenous (IV) drug abuse has risen sharply during the opioid epidemic in the United States.1Slaughter M.S. Badhwar V. Ising M. Ganzel B.L. Sell-Dottin K. Jawitz O.K. et al.Optimum surgical treatment for tricuspid valve infective endocarditis: an analysis of the Society of Thoracic Surgeons National database.J Thorac Cardiovasc Surg. 2021; 161: 1227-1235.e1Google Scholar Although medical management with long-term IV antibiotics is the primary treatment strategy, several patients may not respond to treatment or have residual tricuspid insufficiency requiring operative intervention.1Slaughter M.S. Badhwar V. Ising M. Ganzel B.L. Sell-Dottin K. Jawitz O.K. et al.Optimum surgical treatment for tricuspid valve infective endocarditis: an analysis of the Society of Thoracic Surgeons National database.J Thorac Cardiovasc Surg. 2021; 161: 1227-1235.e1Google Scholar The optimal surgical management of tricuspid valve endocarditis has evolved over the last several decades and has included valvectomy, valve repair, and valve replacement.1Slaughter M.S. Badhwar V. Ising M. Ganzel B.L. Sell-Dottin K. Jawitz O.K. et al.Optimum surgical treatment for tricuspid valve infective endocarditis: an analysis of the Society of Thoracic Surgeons National database.J Thorac Cardiovasc Surg. 2021; 161: 1227-1235.e1Google Scholar,2Protos A.N. Trivedi J.R. Whited W.M. Rogers M.P. Owolabi U. Grubb K.J. et al.Valvectomy versus replacement for the surgical treatment of tricuspid endocarditis.Ann Thorac Surg. 2018; 106: 664-669Google Scholar We report the follow-up and management of a long-term survivor who had previously undergone tricuspid valvectomy for infective endocarditis 30 years previously. A 63-year-old man with history of hypertension, diabetes mellitus, hepatomegaly, and IV drug abuse presented to our clinic in June 2016 with complaints of increasing dyspnea over the last several months, orthopnea, and lower-extremity edema. He developed tricuspid valve infective endocarditis requiring tricuspid valvectomy at an outside institution in June 1986 (30-year history) and was subsequently lost to follow-up. The patient notably had stopped using drugs and led a productive life. Despite his social situation, the patient was adherent with prescribed labetalol, lisinopril, metformin, and sliding-scale insulin. He initially underwent workup at our institution with transthoracic echocardiography, which demonstrated absence of the tricuspid valve with torrential regurgitation and reversal of flow in the inferior vena cava with severe right ventricular (RV) dilatation (RV internal dimension in diastole 6.13 cm) and moderate RV dysfunction (Figure 1). Subsequent cardiac catheterization demonstrated elevated right heart pressures (right atrium 21 mm Hg, RV 50/20 mm Hg) with ventricularized waveform. The patient was discussed at a multidisciplinary heart valve conference and deemed appropriate for tricuspid replacement. Intraoperative transesophageal echocardiography again demonstrated torrential tricuspid regurgitation with dilatation of the right atrium and ventricle. The starting central venous pressure was 26 mm Hg. After sternal reentry, a "beating-heart" strategy for replacement was employed. A 33-mm pericardial valve was placed with no change in the electrocardiogram during the procedure. The patient was weaned from cardiopulmonary bypass uneventfully. Postprocedure transesophageal echocardiography demonstrated a normally functioning tricuspid bioprosthesis without regurgitation. The patient was subsequently discharged on postoperative day 9 after treatment of postoperative tracheobronchitis. Transthoracic echocardiography before discharge again demonstrated satisfactory replacement without significant insufficiency and decreased RV systolic pressure (37 mm Hg) (Figure 2). Recent follow-up transthoracic echocardiography again demonstrated normal tricuspid prosthetic valve function, normalized estimated RV systolic pressure, and RV remodeling without residual dilatation. Surgical intervention for infective endocarditis is indicated in patients who do not respond to initial IV antibiotic treatment, develop heart failure, have embolic events, or residual tricuspid insufficiency.1Slaughter M.S. Badhwar V. Ising M. Ganzel B.L. Sell-Dottin K. Jawitz O.K. et al.Optimum surgical treatment for tricuspid valve infective endocarditis: an analysis of the Society of Thoracic Surgeons National database.J Thorac Cardiovasc Surg. 2021; 161: 1227-1235.e1Google Scholar,3Nath J. Foster E. Heidenreich P.A. Impact of tricuspid regurgitation on long-term survival.J Am Coll Cardiol. 2004; 43: 405-409Google Scholar However, debate over the best surgical intervention for right-sided endocarditis has persisted over the last several decades and included valve repair, replacement, and valvectomy. Recent analyses and consensus guidelines from the American Association for Thoracic Surgery recommend vegetation debridement and repair of the valve when possible, although recent studies suggest replacement remains the most commonly performed procedure.4AATS Surgical Treatment of Infective Endocarditis Consensus Guidelines Writing Committee Chairs Pettersson G.B. Coselli J.S. Hussain S.T. Griffin B. Blackstone E.H. et al.2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: surgical treatment of infective endocarditis: executive summary.J Thorac Cardiovasc Surg. 2017; 153: 1241-1258.e29Google Scholar,5Wallen T.J. Szeto W. Williams M. Atluri P. Arnaoutakis G. Fults M. et al.Tricuspid valve endocarditis in the era of the opioid epidemic.J Card Surg. 2018; 33: 260-264Google Scholar Given concern for the high rates of recidivism and lack of social and financial support in this patient population, tricuspid valvectomy with delayed replacement until completion of a drug treatment program had remained a practical option in this cohort. While previous reports have demonstrated long-term survival of patients without a tricuspid valve, particularly in those with normal pulmonary artery hemodynamics, greater than 25% of these patients are not able to tolerate tricuspid insufficiency and require subsequent replacement. In addition, this cohort may often be difficult to follow clinically, given high recidivism and difficulty of follow-up. We report what we believe to be the lengthiest delay to tricuspid valve replacement following tricuspid valvectomy (30 years) for IV drug abuse after loss to follow-up in the literature. Optimal surgical management is paramount to ensuring superior outcomes in this cohort. Protos and colleagues' recent single-center review2Protos A.N. Trivedi J.R. Whited W.M. Rogers M.P. Owolabi U. Grubb K.J. et al.Valvectomy versus replacement for the surgical treatment of tricuspid endocarditis.Ann Thorac Surg. 2018; 106: 664-669Google Scholar comparing tricuspid valvectomy, repair, and replacement demonstrated similar perioperative outcomes between treatment strategies, however with more patients in the replacement group experiencing unplanned readmissions stemming from infection of their prosthetic valve. Additional analysis of the Society of Thoracic Surgeons National Database by this group revealed valvectomy as an independent predictor of operative mortality and recommended repair of the native valve whenever anatomically possible to avoid recurrent valve infection and prosthetic valve degeneration.1Slaughter M.S. Badhwar V. Ising M. Ganzel B.L. Sell-Dottin K. Jawitz O.K. et al.Optimum surgical treatment for tricuspid valve infective endocarditis: an analysis of the Society of Thoracic Surgeons National database.J Thorac Cardiovasc Surg. 2021; 161: 1227-1235.e1Google Scholar In addition, considerations for preserving RV function should be made when contemplating operative timing. The surgical treatment of right-sided infective endocarditis has changed over the past several decades. Contemporary treatment guidelines recommend preservation of the native valve whenever possible. Symptomatic patients with previous tricuspid resection should undergo replacement when feasible. Commentary: Tricuspid valvectomy: A challenge for a cardiac surgeonJTCVS TechniquesVol. 12PreviewThree decades ago, tricuspid valvectomy was the last resort in certain cases of infective endocarditis associated with septic shock in patients with mostly intravenous illicit drug addiction. Excision of infected tricuspid valve is well known to all the cardiac surgeons. The topic is perhaps timely, as recreational drug use has become an alarming national epidemic. In the recent years, the feasibility of tricuspid valve repair or tricuspid valve replacement has been compared with the valve excision option. Full-Text PDF Open Access

BACKGROUND:Reductive annuloplasty repair of ischemic mitral regurgitation (IMR) is associated with high rates of recurrent MR, which may be improved with etiology-specific annuloplasty rings.METHODS:From October 2005 to May 2015, 128 consecutive patients underwent repair of IMR with the GeoForm ring. Clinical data was extracted from our local Society of Thoracic Surgeons database and electronic medical records. Mortality data was obtained from the Michigan State Social Security Death Index.RESULTS:The average age of patients was 65±11 years with mean pre-op left ventricular ejection fraction (LVEF) of 30%±10% and MR grade of 3.1±0.9 (0-4+). Thirty-day mortality was 4.7%, rate of renal failure 7.9%, rate of atrial fibrillation 27.3%, and no strokes were observed. Of the surviving patients, 89% (109/122) had a follow-up echocardiogram beyond 1 month with a mean echocardiographic follow-up of 59±39 months. LVEF improved from 30%±10% to 38%±14%, P<0.001) while end-diastolic (5.9±0.0 to 5.3±0.9 cm, P<0.001) and end-systolic (5.0±1.0 to 4.4±1.1 cm, P<0.001) left ventricular (LV) diameters decreased, as compared to pre-operative values. Seven patients were found to have recurrent moderate or greater IMR in follow-up to 10 years with three being due to ring dehiscence. One-, 5-, and 10-year freedom from recurrent moderate or severe IMR was 98%, 94%, and 80% respectively. One-, 5-, and 10-year survival was 91%, 77%, and 44%, respectively.CONCLUSIONS:Overall, etiology-specific ring repair of IMR was associated with low rates of recurrent MR on long-term follow-up, coupled with significant LV reverse remodeling and improvement in ejection fraction.

BACKGROUND This study sought to characterize the current US experience of aortic prosthetic valve endocarditis (PVE) compared with native valve endocarditis (NVE).METHODS The Society of Thoracic Surgeons Database was queried for entries of active aortic infective endocarditis (IE). Two analyses were performed: (1) trends of surgical volume and operative mortality (2011-2019); and (2) descriptive and risk-adjusted comparisons between PVE and NVE (2014-2019) using multivariable logistic regression.RESULTS From 2011 to 2019, there was a yearly increase in the proportion of PVE (20.9% to 25.9%; P A .001) with a concurrent decrease in operative mortality(PVE, 22.5% to 10.4%; PA .001; NVE, 10.9% to 8.5%; PA .001). From 2014 to 2019, active aortic IE was identified in 9768 patients (NVE, 6842; PVE, 2926). Aortic root abscess (50.1% vs 25.2%; P A .001), aortic root replacement (50.1% vs 12.8%; P A .001), homograft implantation (27.2% vs 4.1%; P A .001), and operative mortality (12.2% vs 6.4%; P A .001) were higher in PVE. After risk adjustment, PVE (odds ratio [OR], 1.5; 95% CI,1.16-1.94; PA .01), aortic root replacement (OR, 1.49; 95% CI,1.15-1.92; P A .001), Staphylococcus aureus (OR, 1.5; 95% CI,1.23-1.82; PA .001), and unplanned revascularization (OR, 5.83; 95% CI,4.12-8.23; P A .001) or mitral valve surgery (OR, 2.29; 95% CI,1.5-3.51; P A .001) correlated with a higher operative mortality, whereas prosthesis type (P [ .68) was not an independent predictor.CONCLUSIONS IE in the United States has risen over the past decade. However, operative mortality has decreased for both PVE and NVE. PVE, extension of IE requiring aortic root replacement, and additional unplanned surgical in-terventions carry an elevated mortality risk. Prosthesis selection did not affect operative mortality.(Ann Thorac Surg 2022;114:2140-8)(c) 2022 by The Society of Thoracic Surgeons

Refusal of blood product transfusion presents a unique challenge in patients requiring major cardiac surgery. We present a case of a 45-year-old African American female Jehovah's Witness with a history of aortic dissection who presented to the emergency department with worsening back pain. Imaging revealed aneurysmal dilatation of her known Stanford type A dissection measuring 10.9 cm. A staged carotid-subclavian bypass followed by aortic valve, ascending aorta, and aortic arch replacement with debranching was performed using a bloodless strategy. (C) 2021 by The Society of Thoracic Surgeons

A patient with acute pulmonary embolism suffered cardiac arrest, received manual and mechanical cardiopulmonary resuscitation and tissue plasminogen activator before extracorporeal cardiopulmonary resuscitation was initiated. She suffered a type B aortic dissection and retroperitoneal hemorrhage secondary to resuscitation measures. This case report describes high-risk anticoagulation management for contradicting treatment goals in preparation for pulmonary embolectomy on cardiopulmonary bypass.

A 71-year-old woman was admitted with acute hypoxic and hypercapnic respiratory failure and cardiogenic shock, secondary to acute on chronic biventricular systolic and diastolic congestive heart failure and severe aortic and mitral valve stenosis. She further presented with pulmonary hypertension and moderate-to-severe tricuspid regurgitation requiring high and increasing doses of vasopressors. The patient was percutaneously cannulated for venoarterial extracorporeal membrane oxygenation (VA-ECMO) and stabilized on ECMO, with a urine output of 17.3 L within the following 8 days. Balloon valvuloplasty and/or transcatheter aortic valve replacement were discussed but ruled out by the multidisciplinary team considering the mitral valve could not be fully addressed. Though lung function was not fully optimized, a window of opportunity was identified and used for double valve replacement on day 8 of VA-ECMO support. After a 24-hour vasoplegic period, the patient was extubated to continuous positive airway pressure and further transitioned to nasal cannula, following which she recovered well.

Thrombus formation within the ascending aorta is a rare and poorly understood occurrence which may present with peripheral thromboembolic phenomena with devastating outcomes as strokes, limb ischemia, bowl ischemia etc. We report our experience with 5 cases of ascending aortic thrombus over a 2-year period.

Fungal aortic graft infections are unusual and have been reported primarily in the abdominal aortic position. Ascending aortic graft infections secondary to Candida species have been reported rarely and invariably localized to the confines of the aortic graft. We present an interesting case of an ascending aortic graft infection with Candida albicans, with evidence of invasion of the sternum and overlying soft tissues.

Background: To compare the perioperative and long term survival after aortic valve replacement using stentless versus stented valves in a large cohort of patients grouped using propensity score matching.Methods: From 1991 to 2012, 4,563 patients underwent aortic valve replacement with stentless and stented valves at our institution. Propensity score matching identified 444 pairs using 13 independent variables: incidence of operation, smoking status, renal failure, hypertension, diabetes, peripheral vascular disease, cerebrovascular disease, chronic lung disease, ejection fraction, gender, age, valve status, and use of coronary artery bypass graft. Data were collected from our Society of Thoracic Surgeons database and the Social Security Death Index. Groups were compared using univariate and Kaplan-Meier analysis.Results: The two groups demonstrated no significant differences for the 13 matching variables and the majority of 30-day outcomes (p > 0.05). The stented valve group showed a higher incidence of postoperative bleeding (3.6% vs 1.1%, p = 0.015), but a lower incidence of stroke (0.9% vs. 2.9%, p = 0.028). One, five, and 10-year survival was 95.0, 80.7, and 52.8% for stented and 93.2, 80.5, and 51.3% for stentless valves. Overall survival did not differ significantly between the two groups (p = 0.641).Conclusions: Stentless and stented valves had identical 30-day outcomes except for a higher postoperative incidence of bleeding and a lower incidence of stroke in the stented group. There was no significant difference in long term survival between valve types. Both valves may be used for aortic valve replacement with low morbidity and excellent long term survival.

Long cross clamp times have been associated with poor clinical outcomes, yet some patients require extremely long ischemic times to repair complex surgical problems. The purpose of this study was to examine short and mid-term survival and to identify risk factors for mortality and morbidity in patients with cross clamp times greater than or equal to 300 min.

OBJECTIVES Left ventricular assist device (LVAD) implantation may alter right ventricular shape and function and lead to tricuspid regurgitation. This in turn has been reported to be a determinant of right ventricular (RV) failure after LVAD implantation, but the effect of mechanical left ventricular (LV) unloading on the tricuspid annulus is unknown. The aim of the study was to provide insight into the effect of LVAD support on tricuspid annular geometry and dynamics that may help to optimize LV unloading with the least deleterious effect on the right-sided geometry. METHODS In seven open-chest anaesthetized sheep, nine sonomicrometry crystals were implanted on the right ventricle. Additional nine crystals were implanted around the tricuspid annulus, with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Left ventricular unloading was achieved by connecting a cannula in the left atrium and the aorta to a continuous-flow pump. The pump was used for 15 min at a full flow of 3.8 ± 0.3 l/min. Epicardial echocardiography was used to assess the degree of tricuspid insufficiency. Haemodynamic, echocardiographic and sonomicrometry data were collected before and during full unloading. Tricuspid annular area, and the regional and total perimeter were calculated from crystal coordinates, while 3D annular geometry was expressed as the orthogonal distance of each annular crystal to the least squares plane of all annular crystals. RESULTS There was no significant tricuspid regurgitation observed either before or during LV unloading. Right ventricular free wall to septum diameter increased significantly at end-diastole during unloading from 23.6 ± 5.8 to 26.3 ± 6.5 mm (P = 0.009), but the right ventricular volume, tricuspid annular area and total perimeter did not change from baseline. However, the septal part of the annulus significantly decreased its maximal length (38.6 ± 8.1 to 37.9 ± 8.2 mm, P = 0.03). Annular contraction was not altered. The tricuspid annulus had a complex 3D saddle-shaped geometry that was unaffected during experimental conditions. CONCLUSIONS In healthy sheep hearts, left ventricular unloading increased septal-free wall RV diameter and reduced the length of the septal annulus, without altering the motion or geometry of the tricuspid annulus. Acute left ventricular unloading alone in healthy sheep was not sufficient to significantly perturb tricuspid annular dynamics and result in tricuspid insufficiency.

OBJECTIVES:Pulmonary hypertension (PHT) is associated with tricuspid annular dilatation, but the effect of acute increase of pulmonary pressure on three-dimensional (3D) tricuspid annular dynamics and shape is unknown. Better understanding of tricuspid annular dynamics may lead to improved and more durable surgical reparative techniques.METHODS:In nine open-chest anaesthetized sheep nine sonomicrometry crystals were implanted on the right ventricle while on cardiopulmonary bypass. Additional nine crystals were implanted around the tricuspid annulus (TA) with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Two additional equidistant crystals were implanted between each commissure, creating three segments for every region. Pressure transducers were placed in the left ventricular (LV), right ventricular (RV) and right atrium. PHT was induced by acute pulmonary artery constriction with a pneumatic occluder. Sonomicrometry and echocardiographic data were collected before and after induction of PHT. TA area, regional and total perimeter, and 3D annular geometry were calculated from 3D crystal coordinates. Regional annular contraction was defined as the percentage difference between maximal and minimal region length during the cardiac cycle.RESULTS:PHT increased RV pressure from 31 ± 9 mmHg to 46 ± 13 mmHg (P = 0.001) and decreased left ventricular (LV) pressure from 111 ± 24 mmHg to 78 ± 36 mmHg (P = 0.018). There was no significant tricuspid regurgitation observed with PHT. During PHT, the TA area increased by 12 ± 13% from 641 ± 139 mm(2) to 721 ± 177 mm(2) (P = 0.037). The total perimeter increased from 103 ± 11 mm to 109 ± 13 mm (P = 0.02). All annular regions dilated significantly with PHT with 8 ± 10, 5 ± 5 and 5 ± 5% increase in anterior, posterior and septal annular length, respectively (P < 0.05). PHT reduced regional annular contraction in the anterior region only (17 ± 7 vs 14 ± 8%; P = 0.02). The TA had a complex 3D saddle geometry and the shape of the annulus was altered during PHT only in the antero-posterior region.CONCLUSIONS:The changes in tricuspid annular conformation, contractility and its 3D geometry observed during acute ovine PHT may help in the design of new pathology-specific tricuspid annular rings.

Background. The Cox Maze-IV procedure (CMP-IV) has replaced the Cox Maze-III procedure as the most common approach for the surgical treatment of atrial fibrillation (AF). The Food and Drug Administration-regulated AtriCure Bipolar Radiofrequency Ablation of Permanent Atrial Fibrillation (ABLATE) trial sought to demonstrate the safety and efficacy of the CMP-IV performed with the Synergy ablation system (AtriCure, Inc, Cincinnati, OH).Methods. Fifty-five patients (aged 70.5 +/- 9.3 years), 92.7% of whom had nonparoxysmal AF, underwent CMP-IV to terminate AF during a concomitant cardiac surgical procedure. Lesions were created using the AtriCure Synergy bipolar radiofrequency ablation system. All patients were seen for follow-up visits after 30 days, 3 months, and 6 months, with 24-hour Holter monitoring at 6 months. Late evaluation was performed by 48-hour Holter monitoring at an average of 21 months.Results. The primary efficacy endpoint, absence of AF (30 seconds or less) at 6-month follow-up off antiarrhythmic medications (Heart Rhythm Society definition), indicated 76% (38 of 50) were AF free (95% confidence interval: 62.6% to 85.7%). The primary safety endpoint, the rate of major adverse events within 30 days, was 9.1% (5 of 55; 95% confidence interval: 3.9% to 19.6%), with 3.6% mortality (2 of 55). Secondary efficacy endpoints included being AF free with antiarrhythmic drugs (6 months, 84%; 21 months, 75%), successful pulmonary vein isolation (100%), and AF burden at 6 and 21 months. The results, together with those for the secondary safety endpoint (6-month major adverse events), demonstrated that the Synergy system performs comparably to the cut-and-sew Cox Maze-III procedure.Conclusions. The CMP-IV using the AtriCure Synergy system was safe and effective for cardiac surgical patients who had persistent and longstanding persistent AF. (C) 2015 by The Society of Thoracic Surgeons

BACKGROUND:Transcatheter aortic valve implantation (TAVI) has been advocated for very elderly patients with aortic stenosis, and prior cardiac surgery as a less invasive treatment option. Although surgical aortic valve replacement (AVR) is safe and effective in selected elderly patients, the perioperative and mid-term outcomes of AVR in very elderly with prior cardiac surgery are unknown. METHODS:The Society of Thoracic Surgeons (STS) Database at our center enrolled 3,735 patients after AVR since 1997. In this time interval, we identified 61 patients 80 years and older who underwent AVR for severe AS or failed aortic bioprosthesis after having prior cardiac surgery. All clinical parameters were derived from the STS database. Follow-up mortality was assessed using the Social Security Death Index. RESULTS:The average age of the patients was 83 ± 2 years, 77% were male, and 75% underwent an isolated coronary artery bypass graft (CABG) as their first cardiac procedure. The mean ejection fraction was 0.53 ± 0.13. The CABG was performed concurrently in 49% of patients at the time of redo sternotomy and AVR. Stented bioprosthesis was implanted in 61% of patients and stentless in 39%. Perioperative mortality was 1.6% (1 of 61). One, 3, 5, and 7 year survival rates were 85%, 69%, 63%, and 43%, respectively. Patients with AVR only had similar survival to patients who underwent concomitant AVR and CABG. Type of aortic prosthesis did not influence postoperative survival. CONCLUSIONS:In selected patients over the age of 80 with history of prior cardiac surgery, AVR can be performed safely with very good mid-term outcomes. Age alone should not be exclusion criteria for surgical AVR in octogenarians with prior cardiac surgery.

Background: Reductive ring annuloplasty represents the current standard surgical therapy for ischemic mitral regurgitation (IMR); however, the clinical results have been suboptimal. Etiology-specific prostheses such as the GeoForm annuloplasty ring have been designed to better address the annular and subvalvular perturbations associated with IMR. However, clinical experience is limited, and mid-term results are lacking.Methods: We reviewed the clinical outcomes of 86 patients who had undergone implantation of a GeoForm ring at our center from 2005 to 2011. Perioperative mortality and clinical parameters were derived from The Society of Thoracic Surgeons database. Follow-up survival was assessed using the Social Security Death Index. Surviving patients were interviewed by telephone for valve-specific follow-up data and to complete the Medical Outcomes Study, short-form, 36-item, quality-of-life questionnaire.Results: The mean grade of IMR preoperatively was 3.1 +/- 0.8 (range, 1-4+), 0.2 +/- 0.4 in the immediate postoperative period, and 0.7 +/- 0.7 at the last mean follow-up point of 41 months; only 2 patients developed >= 2+ IMR during the follow-up period, for a 5-year freedom from recurrent 2+ IMR of 86%. The mean left ventricular end-diastolic and end-systolic diameters decreased from before to after surgery from 6.0 +/- 0.0 cm to 5.3 +/- 09 cm and 5.0 +/- 0.9 cm to 4.3 +/- 1.1 cm, respectively (P < .001). Perioperative mortality was 5.8% (5 of 86), and 1-, 3-, and 5-year survival was 87%, 81%, and 75%, respectively. At the last follow-up point, 80% of patients were in New York Heart Association class I and II, and their quality of life was equal to, or better than, age-matched controls from the general population.Conclusions: Implantation of the GeoForm ring offers very good control of IMR, with low rate of recurrent IMR at mid-term follow-up. The use of this prosthesis was associated with good perioperative mortality, mid-term survival, and quality of life.