Journal: J Thorac Cardiovasc Surg

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Abstract

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes.

Michelena HI, Della Corte A, Evangelista A, Maleszewski JJ, ... Otto CM, Schäfers HJ
This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 30 Aug 2021; 162:e383-e414
Michelena HI, Della Corte A, Evangelista A, Maleszewski JJ, ... Otto CM, Schäfers HJ
J Thorac Cardiovasc Surg: 30 Aug 2021; 162:e383-e414 | PMID: 34304896
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Abstract

Aortic septotomy to optimize landing zones during thoracic endovascular aortic repair for chronic type B aortic dissection.

Fukuhara S, Khaja MS, Williams DM, Marko X, ... Patel HJ, Kim KM
Objective
The role of thoracic endovascular aortic repair for chronic type B aortic dissection remains controversial. Clinical outcomes of thoracic endovascular aortic repair with recently implemented aortic septotomy strategy were compared with stand-alone thoracic endovascular aortic repair.
Methods
Between 2008 and 2020, 88 patients with chronic type B aortic dissection and degenerative aortic aneurysm underwent a thoracic endovascular aortic repair with or without adjunctive aortic septotomy, consisting of 36 (41%) with de novo chronic type B aortic dissection and 52 (59%) with residual chronic type B aortic dissection after type A aortic dissection repair.
Results
Aortic septotomy was performed in 31 patients (35%) to optimize the proximal (3/31;10%) and distal (31/31;100%) landing zones. The aortic septotomy techniques comprised laser aortic septotomy in 16 patients (52%) and cheese wire septotomy in 15 patients (48%) with a 97% overall technical success rate. The median time interval between aortic dissection occurrence and thoracic endovascular aortic repair was 1.2 years. During follow-up, there were 12 (21%) sudden deaths and 17 (30%) combined aorta-related and sudden deaths in the nonaortic septotomy group, whereas there were no deaths in the septotomy group (P < .001). Patients without aortic septotomy required aortic reinterventions more frequently than those with aortic septotomy (30% vs 7%; P = .014), and 77% of these procedures were related to residual retrograde false lumen flow. Positive aortic remodeling was confirmed in 90% and 37% in the aortic septotomy and nonseptotomy groups, respectively (P < .001).
Conclusions
Stand-alone thoracic endovascular aortic repair outcomes without adjunctive procedures for chronic type B aortic dissection remain unfavorable. In contrast, landing zone optimization using aortic septotomy resulted in a remarkably higher positive aortic remodeling rate. Routine aortic septotomy strategy may positively affect long-term chronic type B aortic dissection survival and expand thoracic endovascular aortic repair candidacy.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2021; epub ahead of print
Fukuhara S, Khaja MS, Williams DM, Marko X, ... Patel HJ, Kim KM
J Thorac Cardiovasc Surg: 24 Aug 2021; epub ahead of print | PMID: 34509296
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Abstract

Impact of concomitant complex cardiac anatomy in nonsyndromic patients with complete atrioventricular septal defect.

Ramgren JJ, Zindovic I, Nozohoor S, Gustafsson R, Hakacova N, Sjögren J
Objective
We studied a cohort of patients with nonsyndromic complete atrioventricular septal defect with and without concomitant complex cardiac anatomy and compared the outcomes after surgical repair.
Methods
Between 1993 and 2018, 62 nonsyndromic patients underwent complete atrioventricular septal defect repair. Sixteen patients (26%) had complex complete atrioventricular septal defect with variables representing concomitant cardiac anatomic complexity: tetralogy of Fallot, double outlet right ventricle, total anomalous pulmonary venous return, concomitant aortic arch reconstruction, multiple ventricular septal defects, staged repair of coarctation of the aorta, and a persisting left superior vena cava. The mean follow-up was 12.7 ± 7.9 years. Baseline variables were retrospectively evaluated and analyzed using univariable logistic regression. Survival was studied using Kaplan-Meier estimates, and group comparisons were performed using the log-rank test. A competing-risk analysis estimated the risk of reoperation with death as the competing event. A Gray\'s test was used to test equality of the cumulative incidence curves between groups.
Results
The perioperative mortality was 3.2% (2/62). Actuarial survival was 100% versus 66.7% ± 14.9% at 10 years in the noncomplex and complex groups, respectively (P < .01). There was no significant difference in the overall reoperation rate between the noncomplex group (7/46; 15%) and the complex group (4/16; 25%) (odds ratio, 1.86; 95% confidence interval, 0.46-7.45; P = .30). The competing-risk analysis demonstrated no significant difference in reoperation between the groups (P = .28).
Conclusions
Our data show that nonsyndromic patients without complex cardiac anatomy have a good long-term survival and an acceptable risk of reoperation similar to contemporary outcomes for patients with complete atrioventricular septal defect with trisomy 21. However, the corresponding group of nonsyndromic patients with concomitant complex cardiac lesions are still a high-risk population, especially regarding mortality.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 19 Aug 2021; epub ahead of print
Ramgren JJ, Zindovic I, Nozohoor S, Gustafsson R, Hakacova N, Sjögren J
J Thorac Cardiovasc Surg: 19 Aug 2021; epub ahead of print | PMID: 34503843
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Abstract

Reappraisal of the role of motor and somatosensory evoked potentials during open distal aortic repair.

Tanaka A, Nguyen H, Dhillon JS, Nakamura M, ... Safi HJ, Estrera AL
Objective
Intraoperative motor and somatosensory evoked potentials have been applied to monitor spinal cord ischemia during repair. However, their predictive values remain controversial. The purpose of this study was to evaluate the impact of motor evoked potentials and somatosensory evoked potentials on spinal cord ischemia during open distal aortic repair.
Methods
Our group began routine use of both somatosensory evoked potentials and motor evoked potentials at the end of 2004. This study used a historical cohort design, using risk factor and outcome data from our department\'s prospective registry. Univariate and multivariable statistics for risk-adjusted effects of motor evoked potentials and somatosensory evoked potentials on neurologic outcome and model discrimination were assessed with receiver operating characteristic curves.
Results
Both somatosensory evoked potentials and motor evoked potentials were measured in 822 patients undergoing open distal aortic repair between December 2004 and December 2019. Both motor evoked potentials and somatosensory evoked potentials were intact for the duration of surgery in 348 patients (42%). Isolated motor evoked potential loss was observed in 283 patients (34%), isolated somatosensory evoked potential loss was observed in 18 patients (3%), and both motor evoked potential and somatosensory evoked potential loss were observed in 173 patients (21%). No spinal cord ischemia occurred in the 18 cases with isolated somatosensory evoked potential loss. When both signals were lost, signal loss happened in the order of motor evoked potentials and then somatosensory evoked potentials. Immediate spinal cord ischemia occurred in none of those without signal loss, 4 of 283 (1%) with isolated motor evoked potential loss, and 15 of 173 (9%) with motor evoked potential plus somatosensory evoked potential loss. Delayed spinal cord ischemia occurred in 12 of 348 patients (3%) with intact evoked potentials, 24 of 283 patients (8%) with isolated motor evoked potentials loss, and 27 of 173 patients (15%) with motor evoked potentials + somatosensory evoked potentials loss (P < .001). Motor evoked potentials and somatosensory evoked potentials loss were each independently associated with spinal cord ischemia. For immediate spinal cord ischemia, no return of motor evoked potential signals at the conclusion of the surgery had the highest odds ratio of 15.87, with a receiver operating characteristic area under the curve of 0.936, whereas motor evoked potential loss had the highest odds ratio of 3.72 with an area under the curve of 0.638 for delayed spinal cord ischemia.
Conclusions
Somatosensory evoked potentials and motor evoked potentials are both important monitoring measures to predict and prevent spinal cord ischemia during and after open distal aortic repairs. Intraoperative motor evoked potential loss is a risk for immediate and delayed spinal cord ischemia after open distal aortic repair, and somatosensory evoked potential loss further adds predictive value to the motor evoked potential.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 19 Aug 2021; epub ahead of print
Tanaka A, Nguyen H, Dhillon JS, Nakamura M, ... Safi HJ, Estrera AL
J Thorac Cardiovasc Surg: 19 Aug 2021; epub ahead of print | PMID: 34517983
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Abstract

Micromechanical force promotes aortic valvular calcification.

Jiang Y, Chen J, Wei F, Wang Y, ... Li G, Dong N
Objective
Calcified aortic valvular disease is known as an inflammation-related process related to force. The purpose of this study was to determine whether micromechanical force could induce valve calcification of porcine valvular interstitial cells and to examine the role of integrin αvβ3 in valvular calcification by using a novel method: magnetic twisting cytometry.
Methods
Porcine valvular interstitial cells were cultured in vitro, and micromechanical force was applied to porcine valvular interstitial cells using magnetic twisting cytometry. Changes in calcification-related factors osteopontin and RUNX2 were detected. By using the calcification medium, the optimal magnetic twisting cytometry parameters for inducing valvular interstitial cell calcification were determined, and a magnetic twisting cytometry calcification promotion model was established. The role of αvβ3 in calcification was studied by using αvβ3 antagonists to block the function of αvβ3.
Results
Reverse transcription polymerase chain reaction assays showed that the expression of osteopontin was enhanced 30 minutes after 25G-1Hz 5 minutes of stimulation. Western blotting assays showed that the expression of osteopontin and RUNX2 was upregulated 24 hours after 25G-1Hz 5 minutes of stimulation. The optimal magnetic twisting cytometry parameter for inducing porcine valvular interstitial cell calcification was 25G-2Hz for 10 minutes. The expression of osteopontin and RUNX2 decreased significantly after the addition of αvβ3 antagonist. Clinically, patients with bicuspid aortic valves had high expression of RUNX2 and β3 in the aortic valve, and β3 significantly correlated with RUNX2.
Conclusions
By using magnetic twisting cytometry, we established a porcine valvular interstitial cell calcification model by micromechanical force stimulation and obtained the optimal parameters. Integrin αvβ3 plays a key role in the aortic valve calcification process.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 13 Aug 2021; epub ahead of print
Jiang Y, Chen J, Wei F, Wang Y, ... Li G, Dong N
J Thorac Cardiovasc Surg: 13 Aug 2021; epub ahead of print | PMID: 34507817
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Abstract

Pan-Canadian initiative on Fundamental Competencies for Transcatheter Cardiac Surgery: A modified Delphi consensus study.

Muller Moran HR, Maurice-Ventouris M, Alharbi M, Ahn BT, Harley JM, Lachapelle KJ
Objective
Transcatheter cardiac procedures have generated increasing interest in trainees and training programs alike. Using the modified Delphi method, we sought to clarify the transcatheter competencies that cardiac surgery residents should be expected to attain by the completion of training.
Methods
Individuals with expertise in transcatheter structural heart and aortic procedures were recruited across Canada. A questionnaire was prepared using a 5-point Likert scale. During 2 rounds, participants rated the competencies that they thought cardiac surgery residents should be required to achieve to perform transcatheter procedures. Data were analyzed and presented to participants between rounds. Competencies rated 4 or higher by at least 80% of respondents after the second round were considered fundamental to transcatheter cardiac surgical training.
Results
A total of 46 individuals participated in the study, including 23 cardiac surgeons, 17 interventional cardiologists, and 6 vascular surgeons. Participants with relevant experience performed a median of 75 (interquartile range, 40-100) transcatheter aortic valve implantations in the prior year as primary or secondary operator and 15 (interquartile range, 11-35) thoracic endovascular aortic repairs in the prior 2 years as primary operator. Median clinical and teaching experience consisted of 13 (interquartile range, 7-19.5) years in practice and 8.5 (interquartile range, 5-15) residents taught per year, respectively. Of the included competencies, 53 were considered fundamental to transcatheter cardiac surgical training.
Conclusions
The identified fundamental competencies can be used to develop educational strategies during transcatheter cardiac surgery training. Future efforts should focus on collecting evidence for their validity.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Aug 2021; epub ahead of print
Muller Moran HR, Maurice-Ventouris M, Alharbi M, Ahn BT, Harley JM, Lachapelle KJ
J Thorac Cardiovasc Surg: 09 Aug 2021; epub ahead of print | PMID: 34465467
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Abstract

Coronary artery bypass with single versus multiple arterial grafts in women: A meta-analysis.

Robinson NB, Lia H, Rahouma M, Audisio K, ... Girardi LN, Gaudino M
Objective
The study objective was to investigate the impact of multiple arterial grafting on long-term all-cause mortality in women undergoing isolated coronary artery bypass grafting.
Methods
A comprehensive search was performed to identify observational studies reporting outcomes after coronary artery bypass grafting reported by sex and stratified into multiple arterial grafting versus single arterial grafting strategies. Articles were considered for inclusion if they were written in English and were propensity-matched observational studies. Included studies were then pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality and spontaneous myocardial infarction. Meta-regression was used to explore the effects of preoperative and intraoperative variables on the primary outcome.
Results
A total of 6 studies with 32,793 women (25,714 single arterial grafting and 7079 multiple arterial grafting) were included. Women who received multiple arterial grafting had lower long-term mortality (incidence rate ratio, 0.86; 95% confidence interval, 0.76-0.96; P = .007) and spontaneous myocardial infarction (incidence rate ratio, 0.80; 95% confidence interval, 0.68-0.93; P = .003) compared with women who received single arterial grafting, but the difference in mortality disappeared when including only the 3 largest studies. There was no difference between groups in operative mortality (odds ratio, 0.99; 95% confidence interval, 0.84-1.17; P = .91). Meta-regression did not identify any associations with the incidence rate ratio for long-term mortality.
Conclusions
The use of multiple arterial grafting in women undergoing coronary artery bypass grafting is associated with lower long-term mortality, although the difference is mostly driven by small series. Further studies, including randomized trials, are needed to evaluate the efficacy of multiple arterial grafting in women undergoing coronary artery bypass grafting.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Aug 2021; epub ahead of print
Robinson NB, Lia H, Rahouma M, Audisio K, ... Girardi LN, Gaudino M
J Thorac Cardiovasc Surg: 09 Aug 2021; epub ahead of print | PMID: 34482958
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Abstract

Long-term outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion.

Brown JA, Navid F, Serna-Gallegos D, Aranda-Michel E, ... Bianco V, Sultan I
Objective
This study sought to report outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion, and secondarily, to report outcomes of this operative approach by type of underlying aortic disease.
Methods
This was an observational study of aortic surgeries from 2010 to 2018. All patients who underwent hemiarch replacement with retrograde cerebral perfusion were included, whereas patients undergoing partial or total arch replacement or concomitant elephant trunk procedures were excluded. Patients were dichotomized into 2 groups by underlying aortic disease; that is, acute aortic dissection (AAD) or aneurysmal degeneration of the aorta. These groups were analyzed for differences in short-term postoperative outcomes, including stroke and operative mortality (Society of Thoracic Surgeons definition). Multivariable Cox analysis was performed to identify variables associated with long-term survival after hemiarch replacement.
Results
A total of 500 patients undergoing hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion were identified, of whom 53.0% had aneurysmal disease and 47.0% had AAD. For the entire cohort, operative mortality was 6.4%, whereas stroke occurred in 4.6% of patients. Comparing AAD with aneurysm, operative mortality and stroke rates were similar across each group. Five-year survival was 84.4% ± 0.02% for the entire hemiarch cohort, whereas 5-year survival was 88.0% ± 0.02% for the aneurysm subgroup and was 80.5% ± 0.03% for the AAD subgroup. On multivariable analysis, AAD was not associated with an increased hazard of death, compared with aneurysm (P = .790).
Conclusions
Morbidity and mortality after hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion are acceptably low, and this operative approach may be as advantageous for AAD as it is for aneurysm.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 02 Aug 2021; epub ahead of print
Brown JA, Navid F, Serna-Gallegos D, Aranda-Michel E, ... Bianco V, Sultan I
J Thorac Cardiovasc Surg: 02 Aug 2021; epub ahead of print | PMID: 34420792
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Abstract

Early surgery is associated with improved long-term survival compared to class I indication for isolated severe tricuspid regurgitation.

Wang TKM, Akyuz K, Xu B, Gillinov AM, ... Griffin BP, Desai MY
Background
Isolated tricuspid valve (TV) surgery has higher mortality compared with other single-valve operations. The optimal timing and indications remain controversial, and earlier surgery before the development of class I surgical indications may improve outcomes. We aimed to compare the characteristics and outcomes of surgery for isolated tricuspid regurgitation (TR), based on class I indication versus an earlier operation.
Methods
Consecutive patients undergoing isolated TV surgery for TR without other concomitant valve surgery at our center during 2004 to 2018 were studied. Indications were divided into class I versus earlier surgery (asymptomatic severe TR with right ventricular dilation and/or dysfunction) for comparative analyses of characteristics and outcomes. The primary outcome was mortality.
Results
The study included 159 patients (91 females [57.2%]; 115 for class I, 44 for early surgery), with a mean age of 59.7 ± 15.6 years, 119 (74.8%) with surgical repairs, and a mean follow-up of 5.1 ± 4.0 years. Overall operative mortality was 5.1% (8 patients) (class I, 7.0%; early surgery, 0.0%; P = .107), and class I had a higher composite morbidity than early surgery (35.7% [n = 41] vs 18.2% [n = 8]; P = .036). On Cox proportional hazard model analysis, class I versus early surgery (hazard ratio [HR], 4.62; 95% confidence interval [CI], 1.09-19.7; P = .04), age (HR, 1.03; 95% CI, 1.00-1.07; P = .046), and diabetes (HR, 2.50; 95% CI, 1.13-5.55; P = .024) were independently associated with higher mortality during follow-up.
Conclusions
Patients with class I indication for isolated TV surgery had worse survival compared with those undergoing earlier surgery before reaching class I indication. Earlier surgery may improve outcomes in these high-risk patients.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Jul 2021; epub ahead of print
Wang TKM, Akyuz K, Xu B, Gillinov AM, ... Griffin BP, Desai MY
J Thorac Cardiovasc Surg: 29 Jul 2021; epub ahead of print | PMID: 34446287
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Abstract

Limitations of receiver operating characteristic curve on imbalanced data: Assist device mortality risk scores.

Movahedi F, Padman R, Antaki JF
Objective
In the left ventricular assist device domain, the receiver operating characteristic is a commonly applied metric of performance of classifiers. However, the receiver operating characteristic can provide a distorted view of classifiers\' ability to predict short-term mortality due to the overwhelmingly greater proportion of patients who survive, that is, imbalanced data. This study illustrates the ambiguity of the receiver operating characteristic in evaluating 2 classifiers of 90-day left ventricular assist device mortality and introduces the precision recall curve as a supplemental metric that is more representative of left ventricular assist device classifiers in predicting the minority class.
Methods
This study compared the receiver operating characteristic and precision recall curve for 2 classifiers for 90-day left ventricular assist device mortality, HeartMate Risk Score and Random Forest for 800 patients (test group) recorded in the Interagency Registry for Mechanically Assisted Circulatory Support who received a continuous-flow left ventricular assist device between 2006 and 2016 (mean age, 59 years; 146 female vs 654 male patients), in whom 90-day mortality rate is only 8%.
Results
The receiver operating characteristic indicates similar performance of Random Forest and HeartMate Risk Score classifiers with respect to area under the curve of 0.77 and Random Forest 0.63, respectively. This is in contrast to their precision recall curve with area under the curve of 0.43 versus 0.16 for Random Forest and HeartMate Risk Score, respectively. The precision recall curve for HeartMate Risk Score showed the precision rapidly decreased to only 10% with slightly increasing sensitivity.
Conclusions
The receiver operating characteristic can portray an overly optimistic performance of a classifier or risk score when applied to imbalanced data. The precision recall curve provides better insight about the performance of a classifier by focusing on the minority class.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Jul 2021; epub ahead of print
Movahedi F, Padman R, Antaki JF
J Thorac Cardiovasc Surg: 29 Jul 2021; epub ahead of print | PMID: 34446286
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Abstract

Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and bioprosthetic valves: A meta-analysis.

Yokoyama Y, Briasoulis A, Ueyama H, Mori M, ... Takagi H, Kuno T
Background
The optimal anticoagulation strategy for patients with bioprosthetic valves and atrial fibrillation remains uncertain. We conducted a meta-analysis using updated evidence comparing direct anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with bioprosthetic valves and atrial fibrillation.
Methods
Medline and Embase were searched through March 2021 to identify randomized controlled trials (RCTs) and observational studies investigating the outcomes of DOAC therapy and VKA therapy in patients with bioprosthetic valves and atrial fibrillation. The outcomes of interest were all-cause death, major bleeding, and stroke or systemic embolism.
Results
Our analysis included 4 RCTs and 6 observational studies enrolling a total of 6405 patients with bioprosthetic valves and atrial fibrillation assigned to a DOAC group (n = 2142) or a VKA group (n = 4263). Pooled analysis demonstrated the similar rates of all-cause death (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.77-1.05; P = .18; I2 = 0%) in the DOAC and VKA groups. However, the rate of major bleeding was significantly lower in the DOAC group (HR, 0.66; 95% CI, 0.48-0.89; P = .006; I2 = 0%), whereas the rate of stroke or systemic embolism was similar in the 2 groups (HR, 0.72; 95% CI, 0.44-1.17; P = .18; I2 = 39%).
Conclusions
DOAC might decrease the risk of major bleeding without increasing the risk of stroke or systemic embolism or all-cause death compared with VKA in patients with bioprosthetic valves and atrial fibrillation.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 28 Jul 2021; epub ahead of print
Yokoyama Y, Briasoulis A, Ueyama H, Mori M, ... Takagi H, Kuno T
J Thorac Cardiovasc Surg: 28 Jul 2021; epub ahead of print | PMID: 34417050
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Abstract

Influence of right ventricular pressure and volume overload on right and left ventricular diastolic function.

Jani V, Konecny F, Shelby A, Kulkarni A, ... Danford D, Kutty S
Background
Ventricular interdependence may account for altered ventricular mechanics in congenital heart disease. The present study aimed to identify differences in load-dependent right ventricular (RV)-left ventricular (LV) interactions in porcine models of pulmonary stenosis (PS) and pulmonary insufficiency (PI) by invasive admittance-derived hemodynamics in conjunction with noninvasive cardiovascular magnetic resonance (CMR).
Methods
Seventeen pigs were used in the study (7 with PS, 7 with PI, and 3 controls). Progressive PS was created by tightening a Teflon tape around the pulmonary artery, and PI was created by excising 2 leaflets of the pulmonary valve. Admittance catheterization data were obtained for the RV and LV at 10 to 12 weeks after model creation, with the animal ventilated under temporary diaphragm paralysis. CMR was performed in all animals immediately prior to pressure-volume catheterization.
Results
In the PS group, RV contractility was increased, manifested by increased end-systolic elastance (mean difference, 1.29 mm Hg/mL; 95% confidence interval [CI], 0.57-2.00 mm Hg/mL). However, in the PI group, no significant changes were observed in RV systolic function despite significant changes in RV diastolic function. In the PS group, LV end-systolic volume was significantly lower compared with controls (mean difference, 25.1 mL; 95% CI, -40.5 to -90.7 mL), whereas in the PI group, the LV showed diastolic dysfunction, demonstrated by an elevated isovolumic relaxation constant and ventricular stiffness (mean difference, 0.03 mL-1; 95% CI, -0.02 to 0.09 mL-1).
Conclusions
The LV exhibits systolic dysfunction and noncompliance with PI. PS is associated with preserved LV systolic function and evidence of some LV diastolic dysfunction. Interventricular interactions influence LV filling and likely account for differential effects of RV pressure and volume overload on LV function.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Jul 2021; epub ahead of print
Jani V, Konecny F, Shelby A, Kulkarni A, ... Danford D, Kutty S
J Thorac Cardiovasc Surg: 27 Jul 2021; epub ahead of print | PMID: 34446290
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Abstract

Surgical versus transcatheter repair for secondary mitral regurgitation: A propensity score-matched cohorts comparison.

Okuno T, Praz F, Kassar M, Biaggi P, ... Wenaweser P, Reineke D
Objectives
To compare the efficacy and clinical outcomes of transcatheter edge-to-edge mitral valve repair (TMVr) and surgical mitral valve repair (SMVr) among patients with secondary mitral regurgitation (SMR).
Methods
Consecutive patients with SMR treated using either TMVr (n = 199) or SMVr (n = 222) at 2 centers were included and retrospectively analyzed. To account for differences in patient demographic characteristics, 1:1 propensity score matching was performed. The primary endpoint was all-cause death within 2 years after the procedure.
Results
The study population consisted of 202 matched patients. At 2 years, all-cause mortality was 24.3% for TMVr and 23.0% for SMVr (hazard ratio, 0.97; 95% confidence interval, 0.55-1.71; P = .909). Severe heart failure symptoms at 2 years were less prevalent after SMVr (New York Heart Association functional class III or IV: 13.5% vs 29.5%; P = .032) than after TMVr. A higher proportion of the SMVr patients had SMR reduction to none or mild at discharge (90.8% vs 72.0%; P < .001) and 2 years (86.5% vs 59.6%; P < .001). Among patients who achieved none or mild MR at discharge, 7 patients (10.1%) in the SMVr group and 15 (34.9%) in the TMVr group had progression to moderate or greater MR at 2 years (P = .003). Left ventricular ejection fraction (LVEF) significantly improved (+10.1% ± 11.1%; P < .001) after SMVr (LVEF at 2 years: 45.7% ± 12.8%), whereas it remained unchanged (-1.3% ± 8.9%; P = .260) after TMVr (LVEF at 2 years: 34.0% ± 13.2%).
Conclusions
In this propensity score-matched analysis, there was no significant difference in 2-year survival between TMVr and SMVr, despite greater and more durable SMR reduction, as well as LVEF improvement in the surgical group.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Jul 2021; epub ahead of print
Okuno T, Praz F, Kassar M, Biaggi P, ... Wenaweser P, Reineke D
J Thorac Cardiovasc Surg: 27 Jul 2021; epub ahead of print | PMID: 34446288
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Abstract

Prevention of postoperative delirium after cardiovascular surgery: A team-based approach.

Enomoto K, Kosaka S, Kimura T, Matsubara M, ... Mieno M, Okamura H
Objective
We investigated the efficacy of the Delirium Team Approach program for delirium prevention after cardiovascular surgery.
Methods
We retrospectively investigated 256 patients who underwent cardiac or thoracic vascular surgery between May 2017 and May 2020. We compared the outcomes before and after implementation of the Delirium Team Approach program in December 2018. The program included the following components: (a) educational sessions for the medical team regarding delirium and its management, (b) review of preprinted physician orders for insomnia and agitation, and (c) routine screening for delirium. We investigated the early outcomes and effects of the Delirium Team Approach program on postoperative delirium.
Results
The incidence of postoperative delirium significantly decreased from 53.3% to 37.0% after implementation of the Delirium Team Approach program (P = .008). Although no intergroup differences were observed in the rates of stroke and reexploration for bleeding, the length of intensive care unit stay and the overall length of postoperative hospital stay were shorter in the postintervention group. Hospital costs, excluding surgery, and the cost during intensive care unit stay were lower in the postintervention group. Multivariable analysis showed that the Delirium Team Approach program was associated with a reduction in postoperative delirium (odds ratio, 0.38; 95% confidence interval, 0.21-0.67; P = .001). Other predictors of delirium included age, dementia, chronic kidney disease, and intubation time. After risk adjustment using propensity score matching, the rate of postoperative delirium was lower in the postintervention group.
Conclusions
Implementation of the Delirium Team Approach program was associated with a lower incidence of postoperative delirium in patients who underwent cardiovascular surgery.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 23 Jul 2021; epub ahead of print
Enomoto K, Kosaka S, Kimura T, Matsubara M, ... Mieno M, Okamura H
J Thorac Cardiovasc Surg: 23 Jul 2021; epub ahead of print | PMID: 34417049
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Abstract

Survival effect of radial artery usage in addition to bilateral internal thoracic arterial grafting: A meta-analysis.

Formica F, Maestri F, D\'Alessandro S, Di Mauro M, ... Gallingani A, Nicolini F
Objective
Little evidence shows whether the radial artery (RA) as third arterial graft provides superior outcomes compared with the use of the bilateral internal thoracic artery (BITA) and saphenous vein (SV) graft in patients undergoing coronary artery bypass grafting. A meta-analysis of propensity score-matched observational studies that compared the long-term outcomes of coronary artery bypass grafting with the use of BITA and the RA (BITA + RA) versus BITA and SV (BITA + SV) was performed.
Methods
Electronic databases from January 2000 to November 2020 were screened. Studies that reported long-term mortality were analyzed. The primary outcome was long-term overall mortality. A secondary end point was in-hospital/30-day mortality. Pooled hazard ratio with 95% confidence interval (CI) were calculated for survival and time-to-event analysis according to a random effect model. Differences were expressed as odds ratio with 95% CI for in-hospital/30-day mortality.
Results
Six propensity score-matched studies that reported on 2500 matched patients (BITA + RA: 1250; BITA + SV: 1250) were identified for comparison. The use of BITA + RA was not statistically associated with early mortality (odds ratio, 0.90; 95% CI, 0.36-2.28; P = .83). The mean follow-up time ranged from 7.5 to 12 years. The pooled analysis of long-term survival revealed a significant difference between the 2 groups favoring BITA + RA treatment (hazard ratio, 0.71; 95% CI, 0.50-0.91; P = .031). The survival rate for BITA + RA versus BITA + SV at 5, 10, and 15 years were: 96.2% versus 94.8%, 88.9% versus 87.4%, and 83% versus 77.9%, respectively (log rank test, P = .02).
Conclusions
In patients with coronary artery bypass grafting, BITA + RA usage is not associated with higher rates of operative risk and is associated with superior long-term overall survival.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 23 Jul 2021; epub ahead of print
Formica F, Maestri F, D'Alessandro S, Di Mauro M, ... Gallingani A, Nicolini F
J Thorac Cardiovasc Surg: 23 Jul 2021; epub ahead of print | PMID: 34462132
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Impact:
Abstract

Intraoperative neurophysiologic monitoring during aortic arch surgery.

Sultan I, Brown JA, Serna-Gallegos D, Thirumala PD, ... Navid F, Gleason TG
Objective
To evaluate the ability of intraoperative neurophysiologic monitoring (IONM) during aortic arch reconstruction with hypothermic circulatory arrest (HCA) to predict early (<48 hours) adverse neurologic events (ANE; stroke or transient ischemic attack) and operative mortality.
Methods
This was an observational study of aortic arch surgeries requiring HCA from 2010 to 2018. Patients were monitored with electroencephalogram (EEG) and somatosensory evoked potentials (SSEP). Baseline characteristics and postoperative outcomes were compared according to presence or absence of IONM changes, which were defined as any acute variation in SSEP or EEG, compared with baseline. Multivariable logistic regression analysis was used to assess the association of IONM changes with operative mortality and early ANE.
Results
A total of 563 patients underwent aortic arch reconstruction with HCA and IONM. Of these, 119 (21.1%) patients had an IONM change, whereas 444 (78.9%) did not. Patients with IONM changes had increased operative mortality (22.7% vs 4.3%) and increased early ANE (10.9% vs 2.9%). In multivariable analysis, SSEP changes were correlated with early ANE (odds ratio [OR], 4.68; 95% confidence interval [CI], 1.51-14.56; P = .008), whereas EEG changes were not (P = .532). Permanent SSEP changes were correlated with early ANE (OR, 4.56; 95% CI, 1.51-13.77; P = .007), whereas temperature-related SSEP changes were not (P = .997). Finally, any IONM change (either SSEP or EEG) was correlated with operative mortality (OR, 5.82; 95% CI, 2.72-12.49; P < .001).
Conclusions
Abnormal IONM events during aortic arch reconstruction with HCA portend worse neurologic outcomes and operative mortality and have a negative predictive value of 97.1%. SSEP might be more sensitive than EEG for predicting early ANE, especially when SSEP changes are permanent.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Jul 2021; epub ahead of print
Sultan I, Brown JA, Serna-Gallegos D, Thirumala PD, ... Navid F, Gleason TG
J Thorac Cardiovasc Surg: 21 Jul 2021; epub ahead of print | PMID: 34384591
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Impact:
Abstract

Lobar size reduction in lung transplantation: A propensity score study.

Schiavon M, Mendogni P, Faccioli E, Lorenzoni G, ... Rea F, Lung Transplantation Working Group
Objective
For small-sized recipients of lung transplantation, the time span for organ reception from standard donors is generally longer than for normal-sized patients. Despite its underuse, lobar reduction may be a concrete option for these patients. This study aims to assess early and long-term outcomes associated with lobar reduction in lung transplantation.
Methods
A retrospective study was performed on 608 consecutive lung transplantations at 2 centers between January 2005 and August 2019 (559 standard lung transplantations [standard transplantation] and 49 with lobar reduction [lung transplantation group]). A propensity-score weighting approach was used to account for potential confounding related to patients\' nonrandom allocation to the 2 intervention groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach.
Results
The propensity score was estimated on 571 patients (522 in standard transplantation group and 49 in lung transplantation group). In terms of early outcomes, the lung transplantation group showed a higher percentage of severe primary graft dysfunction at 0 hours and reported longer intensive care unit stay than the standard transplantation group. No other differences in terms of morbidity, mortality, mechanical ventilation time, hospital stay, and anastomotic complications were observed. Although the lung transplantation group showed worse long-term pulmonary function, the 2 populations had comparable survival outcomes.
Conclusions
The use of lobar reduction showed early and long-term results comparable to those after standard lung transplantation. Although a higher rate of early severe primary graft dysfunction and slightly reduced respiratory function were detected in the lobar group, these did not affect patients\' morbidity and survival.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Jul 2021; epub ahead of print
Schiavon M, Mendogni P, Faccioli E, Lorenzoni G, ... Rea F, Lung Transplantation Working Group
J Thorac Cardiovasc Surg: 20 Jul 2021; epub ahead of print | PMID: 34353616
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Impact:
Abstract

Early outcomes of patients with Marfan syndrome and acute aortic type A dissection.

Farag M, Büsch C, Rylski B, Pöling J, ... German Registry for Acute Aortic Dissection Type A Working Group of the German Society of Thoracic, Cardiac and Vascular Surgery
Background
Acute aortic Stanford type A dissection remains a frequent and life-limiting event for patients with Marfan syndrome. Outcome results in this high-risk group are limited.
Methods
The German Registry for Acute Aortic Dissection Type A collected the data of 56 centers between July 2006 and June 2015. Of 3385 patients undergoing operations for acute aortic Stanford type A dissection, 117 (3.5%) were diagnosed with Marfan syndrome. We performed a propensity score match comparing patients with Marfan syndrome with patients without Marfan syndrome in a 1:2 fashion.
Results
Patients with Marfan syndrome were significantly younger (42.9 vs 62.2 years; P < .001), predominantly male (76.9% vs 62.9%; P = .002), and less catecholamine dependent (9.4% vs 20.3%; P = .002) compared with the unmatched cohort. They presented with aortic regurgitation (41.6% vs 23.0%; P < .001) and involvement of the supra-aortic vessels (50.4% vs 39.5%; P = .017) more often. Propensity matching revealed 82 patients with Marfan syndrome (21 female) with no significant differences in baseline characteristics compared with patients without Marfan syndrome (n = 159, 36 female; P = .607). Although root preservation was more frequent in patients with Marfan syndrome, procedure types did not differ significantly (18.3% vs 10.7%; P = .256). Aortic arch surgery was performed more frequently in matched patients (87.5% vs 97.8%; P = .014). Thirty-day mortality did not differ between patients with and without Marfan syndrome (19.5% vs 20.1%; P = .910). Multivariate regression showed no influence of Marfan syndrome on 30-day mortality (odds ratio, 0.928; 95% confidence interval, 0.346-2.332; P = .876).
Conclusions
Marfan syndrome does not adversely affect 30-day outcomes after surgical repair for acute aortic Stanford type A dissection compared with a matched cohort. Long-term outcome analysis is needed to account for the influence of further downstream interventions.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Jul 2021; epub ahead of print
Farag M, Büsch C, Rylski B, Pöling J, ... German Registry for Acute Aortic Dissection Type A Working Group of the German Society of Thoracic, Cardiac and Vascular Surgery
J Thorac Cardiovasc Surg: 20 Jul 2021; epub ahead of print | PMID: 34446289
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Impact:
Abstract

Aortic valve reintervention after transcatheter aortic valve replacement.

Fukuhara S, Nguyen CTN, Kim KM, Yang B, ... Patel HJ, Deeb GM
Background
Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), there are scant data regarding aortic valve reintervention after initial TAVR.
Methods
Between 2011 and 2019, 1487 patients underwent a TAVR at the University of Michigan. Among these, 24 (1.6%) patients required an aortic valve reintervention. Additionally, 4 patients who received a TAVR at another institution underwent a valve reintervention at our institution. We retrospectively reviewed these 28 patients.
Results
The median age was 72 years, 36% were female and 86% of implanted TAVR devices were self-expandable. The leading indications for reintervention were structural valve degeneration (39%) and paravalvular leak (36%). The cumulative incidence of aortic valve reintervention was 4.6% at 8 years. Most (71%) were deemed unsuitable for repeat TAVR because of the need for concurrent cardiac procedures (50%), unfavorable anatomy (45%), or endocarditis (10%). TAVR valve explant was associated with frequent concurrent procedures, consisting of aortic repair (35%), mitral repair/replacement (35%), tricuspid repair (25%), and coronary artery bypass graft (20%). Seventy-one percent of aortic procedures were unplanned but proved necessary because of severe adhesion of the devices to the contacting tissue. There were 3 (15%) in-hospital mortalities in the TAVR valve explant group, whereas there was no mortality in the repeat TAVR group.
Conclusions
Repeat TAVR procedure was frequently not feasible because of unfavorable anatomy and/or the need for concurrent cardiac procedures. Careful assessment of TAVR procedure repeatability should be weighed at the initial TAVR workup especially in younger patients who are expected to require a valve reintervention.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 19 Jul 2021; epub ahead of print
Fukuhara S, Nguyen CTN, Kim KM, Yang B, ... Patel HJ, Deeb GM
J Thorac Cardiovasc Surg: 19 Jul 2021; epub ahead of print | PMID: 34364682
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Impact:
Abstract

Robotic-assisted tracheobronchoplasty: Quality of life and pulmonary function assessment on intermediate follow-up.

Lazzaro RS, Patton BD, Wasserman GA, Karp J, ... Inra ML, Scheinerman SJ
Objective
The initial description of robotic tracheobronchoplasty for the treatment of tracheobronchomalacia demonstrated feasibility, safety, and short-term symptomatic and functional improvement. The purpose of the current study was to demonstrate intermediate outcomes in postoperative pulmonary function and quality of life after robotic tracheobronchoplasty.
Methods
We retrospectively reviewed prospectively collected clinical data from 42 patients who underwent robotic tracheobronchoplasty from May 2016 to December 2017. The Institutional Review Board or equivalent ethics committee of the Northwell Health approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the Institutional Review Board.
Results
A total of 42 patients underwent robotic tracheobronchoplasty during the study period. Median total follow-up is 40 months. There was 1 death since surgery from an unrelated disease. Significant decreases in St George\'s Respiratory Questionnaire total score (preoperative mean: 64.01, postoperative mean: 38.91, P = .002), St George\'s Respiratory Questionnaire symptom score (preoperative median: 82.6, postoperative median: 43.99, P < .001), and St George\'s Respiratory Questionnaire impact score (preoperative median: 55.78, postoperative median: 25.95, P < .001) were apparent at a median follow-up of 13 months. Comparison of preoperative and postoperative pulmonary function tests revealed a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 74% vs postoperative median: 82%, P = .001), forced vital capacity (preoperative median: 68.5% vs postoperative median: 80.63%, P < .001), and peak expiratory flow (preoperative median: 61.5% vs postoperative median: 75%, P = .02) measured at a median follow-up of 29 months.
Conclusions
Robotic tracheobronchoplasty is associated with low intermediate-term mortality. Robotic tracheobronchoplasty results in significant improvement in quality of life and postoperative pulmonary function. Longer-term follow-up is necessary to continue to elucidate the effect of robotic tracheobronchoplasty on halting pathologic progression of tracheobronchomalacia and to determine the long-term impact of tracheobronchoplasty on symptomatic and functional improvement.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print
Lazzaro RS, Patton BD, Wasserman GA, Karp J, ... Inra ML, Scheinerman SJ
J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print | PMID: 34340852
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Impact:
Abstract

Neoadjuvant pemetrexed plus cisplatin followed by pleurectomy for malignant pleural mesothelioma.

Hasegawa S, Yokoi K, Okada M, Tanaka F, ... Daimon T, Nakano T
Purpose
Despite becoming the preferred surgical technique for malignant pleural mesothelioma, pleurectomy/decortication has received few prospective clinical trials. Therefore, the Japan Mesothelioma Interest Group conducted a prospective multi-institutional study to evaluate the feasibility of neoadjuvant chemotherapy followed by pleurectomy/decortication.
Methods
Patients with histologically confirmed, resectable malignant pleural mesothelioma underwent neoadjuvant chemotherapy comprising pemetrexed 500 mg/m2 plus cisplatin 75 mg/m2 for 3 cycles, followed by pleurectomy/decortication. The primary end point was macroscopic complete resection rate regardless of the surgical technique used.
Results
Among the 24 patients enrolled, 20 received neoadjuvant chemotherapy and 18 proceeded to surgery, all of whom achieved macroscopic complete resection. Pleurectomy/decortication was performed in 15 patients. The trial satisfied the primary end point, with a macroscopic complete resection rate of 90% (18/20, 95% confidence interval, 68.3-98.8). No treatment-related 30- and 90-day mortality occurred. The overall survival after 1 and 2 years and median overall survival after registration were 95.0% (95% confidence interval, 69.5-99.3), 70.0% (95% confidence interval, 45.1-85.3), and 3.45 years (95% confidence interval, 1.64 to not available), respectively. The cumulative incidence of progression after 1 and 2 years and median time to progression were 33.3% (95% confidence interval, 17.3-64.1), 61.1% (95% confidence interval, 42.3-88.3), and 1.71 years (95% confidence interval, 1.00-2.99), respectively. The best postoperative value for forced expiratory volume was 78.0% of preoperative values.
Conclusions
Neoadjuvant chemotherapy followed by pleurectomy/decortication was feasible with acceptable survival and mortality/morbidity. Postoperative pulmonary function was approximately 80% of the preoperative pulmonary function.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print
Hasegawa S, Yokoi K, Okada M, Tanaka F, ... Daimon T, Nakano T
J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print | PMID: 34419248
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Impact:
Abstract

Hypoxia-inducible factor 1-alpha enhances the secretome to rejuvenate adult cardiosphere-derived cells.

Saha P, Kim M, Tulshyan A, Guo Y, ... Kaushal S, Sharma S
Objective
After cardiac injury, endogenous repair mechanisms are ineffective. However, cell-based therapies provide a promising clinical intervention based on their ability to restore and remodel injured myocardium due to their paracrine factors. Recent clinical trials have demonstrated that adult cardiosphere-derived cell therapy is safe for the treatment of ischemic heart failure, although with limited regenerative potential. The limited efficiency of cardiosphere-derived cells after myocardial infarction is due to the inferior quality of their secretome. This study sought to augment the therapeutic potential of cardiosphere-derived cells by modulating hypoxia-inducible factor-1α, a regulator of paracrine factors.
Methods
Cardiosphere-derived cells were isolated and expanded from the right atrial appendage biopsies of patients undergoing cardiac surgery. To study the effect of hypoxia-inducible factor-1α on the secretome, cardiosphere-derived cells were transduced with hypoxia-inducible factor-1α-overexpressing lentivirus, and various cardioprotective factors within the secretome were quantified using enzyme-linked immunosorbent assays. Comparative analysis of the regenerative potential of cardiosphere-derived cells was performed in a rat myocardial infarction model.
Results
Mechanistically, overexpression of hypoxia-inducible factor-1α in adult cardiosphere-derived cells led to the enrichment of the secretome with vascular endothelial growth factor A, angiopoietin 1, stromal cell-derived factor 1α, and basic fibroblast growth factor. Intramyocardial administration of cardiosphere-derived cells transduced with hypoxia-inducible factor-1α after myocardial infarction significantly improved left ventricular ejection fraction, fractional shortening, left ventricular end-systolic volume, and cardiac output. Functional improvement of the rat heart correlated with improved adaptive remodeling of the infarcted myocardium by enhanced angiogenesis and decreased myocardial fibrosis. We also showed that hypoxia-inducible factor-1α expression in cardiosphere-derived cells was adversely affected by aging.
Conclusions
Hypoxia-inducible factor-1α improves the functional potency of cardiosphere-derived cells to preserve myocardial function after myocardial infarction by enriching the cardiosphere-derived cells\' secretome with cardioprotective factors. This strategy may be useful for improving the efficacy of allogeneic cell-based therapies in future clinical trials.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print
Saha P, Kim M, Tulshyan A, Guo Y, ... Kaushal S, Sharma S
J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print | PMID: 34465468
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Impact:
Abstract

Diastolic inflow is associated with inefficient ventricular flow dynamics in Fontan patients.

Stone ML, Schäfer M, DiMaria MV, von Alvensleben JC, ... Jaggers J, Mitchell MB
Objective
This study used cardiac magnetic resonance imaging to evaluate flow characteristics and ventricular hemodynamics for children with single right (hypoplastic left heart syndrome) and single left (hypoplastic right heart syndrome) systemic ventricle anatomy after Fontan palliation compared with normal biventricular controls.
Methods
Twenty children with single ventricle anatomy (hypoplastic left heart syndrome, n = 10; hypoplastic right heart syndrome, n = 10) underwent standardized 4-dimensional flow cardiac magnetic resonance and were compared with age-matched controls (n = 10). End-diastolic volume was partitioned into 4 defined components of variable kinetic energy (direct flow, retained inflow, delayed ejection, and residual volume) and compared between groups. Further, volumetric and functional parameters as defined by cardiac magnetic resonance were evaluated.
Results
Children with hypoplastic left heart syndrome had significantly increased indexed end-diastolic and end-systolic volumes compared with both hypoplastic right heart syndrome and control groups. Flow component analysis demonstrated diastolic inefficiency in both hypoplastic left heart syndrome and hypoplastic right heart syndrome groups compared with controls as defined by decreased direct flow and increased residual volumes. Decreased direct flow correlated with decreased ejection fraction and increased end-diastolic and end-systolic volume indices. Increased residual volume correlated with decreased ejection fraction and increased end-systolic volume index.
Conclusions
Fontan-palliated patients with single ventricle physiology (hypoplastic left heart syndrome and hypoplastic right heart syndrome) demonstrate altered and inefficient flow patterns in the systemic ventricle as defined by 4-dimensional flow cardiac magnetic resonance compared with normal biventricular controls. Decreased direct flow and increased residual volume indicate that diastolic ventricular dysfunction is prevalent after Fontan palliation. This study provides a foundation for future predictive modeling and cardiac magnetic resonance flow diagnostic studies in this high-risk patient population.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print
Stone ML, Schäfer M, DiMaria MV, von Alvensleben JC, ... Jaggers J, Mitchell MB
J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print | PMID: 34429192
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Impact:
Abstract

Survival after aortic root replacement with a stentless xenograft is determined by patient characteristics.

Dagnegård HH, Bekke K, Kolseth SM, Glaser N, ... Ihlemann N, Smerup MH
Objectives
Our objective was to examine intermediate-term survival and reinterventions in unselected patients, stratified according to indication, who received a Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis as a full aortic root replacement.
Methods
Data from medical records were retrospectively collected for patients who had aortic root replacement using Freestyle bioprostheses between 1999 and 2018 at 6 North-Atlantic centers. Survival status was extracted from national registries and results stratified according to indication for surgery.
Results
We included 1030 implantations in 1008 patients with elective indications for surgery: aneurysm (39.8%), small root (8.3%), and other (13.8%), and urgent/emergent indications: endocarditis (26.7%) and Stanford type A aortic dissection (11.4%). Across indications, 46.3% were nonelective cases and 34.0% were reoperations. Median age was 66.0 (interquartile range, 58.0-71.8) years and median follow-up was 5.0 (interquartile range, 2.6-7.9) years. Thirty-day mortality varied from 2.9% to 27.4% depending on indication. Intermediate survival for 90-day survivors with elective indications were not different from the general population standardized for age and sex (P = .95, .83, and .16 for aneurysms, small roots, and other, respectively). In contrast, patients with endocarditis and type A dissection had excess mortality (P < .001). Freedom from valve reinterventions was 95.0% and 94.4% at 5 and 8 years, respectively. In all, 52 patients (5.2%) underwent reinterventions, most because of endocarditis.
Conclusions
At intermediate term follow-up this retrospective study provides further support for the use of the Freestyle bioprosthesis in the real-world setting of diverse, complex, and often high-risk aortic root replacement and suggests that outcome is determined by patient and disease, rather than by prosthesis, characteristics.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print
Dagnegård HH, Bekke K, Kolseth SM, Glaser N, ... Ihlemann N, Smerup MH
J Thorac Cardiovasc Surg: 16 Jul 2021; epub ahead of print | PMID: 34452760
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Impact:
Abstract

American Association for Thoracic Surgery Summer Intern Scholarship-Over a decade of experience.

Chan PG, Liang S, Smood B, Fann JI, Kilic A
Objective
The study objective was to evaluate the experience of previous American Association for Thoracic Surgery Summer Intern Scholarship recipients.
Methods
A database of recipients of the American Association for Thoracic Surgery Summer Intern Scholarship in Cardiothoracic Surgery provided by the American Association for Thoracic Surgery was analyzed. A questionnaire was sent via email to recipients with 10 questions within the survey to assess the types of exposure during the internship, the impact of the internship on career choices, the current career setting, and any additional thoughts regarding the internship.
Results
Between 2007 and 2017, there were 356 awardees of the American Association for Thoracic Surgery Summer Intern Scholarship. These awardees were from 41 different medical schools and went to 39 different sponsoring institutions. Ultimately, 55 (15.5%) medical students chose a career in cardiothoracic surgery, with 153 (43.0%) awardees deciding to pursue a surgical subspecialty. Of those who received our survey, 75 awardees responded (29.2%). A majority of the American Association for Thoracic Surgery Summer Interns were exposed to the sponsoring surgeon (98.7%, n = 74) and operating room (88.0%, n = 66) on at least a weekly basis during the 8-week internship. All of the respondents participated in basic science or clinical research at their sponsoring institution. Some 92.0% (n = 69) of the awardees highly recommended this scholarship to medical students interested in cardiothoracic surgery.
Conclusions
The awardees of the American Association for Thoracic Surgery Summer Intern Scholarship come from a variety of medical schools and visited a diverse group of sponsoring institutions. The 8-week program provides valuable early exposure for medical students to cardiothoracic surgeons, the operating room, and research opportunities. This experience was highly recommended by prior recipients to medical students interested in cardiothoracic surgery.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 14 Jul 2021; epub ahead of print
Chan PG, Liang S, Smood B, Fann JI, Kilic A
J Thorac Cardiovasc Surg: 14 Jul 2021; epub ahead of print | PMID: 34334173
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Impact:
Abstract

A tool to assess nontechnical skills of perfusionists in the cardiac operating room.

Dias RD, Riley W, Shann K, Likosky DS, Fitzgerald D, Yule S
Objectives
This study aimed to develop the Perfusionists\' Intraoperative Non-Technical Skills tool, specifically to the perfusionists\' context, and test its inter-rater reliability.
Methods
An expert panel was convened to review existing surgical nontechnical skills taxonomies and develop the Perfusionists\' Intraoperative Non-Technical Skills tool. During a workshop held at a national meeting, perfusionists completed the Perfusionists\' Intraoperative Non-Technical Skills ratings after watching 4 videos displaying simulated cardiac operations. Two videos showed \"good performance,\" and 2 videos showed \"poor performance.\" Inter-rater reliability analysis was performed and intraclass correlation coefficient was reported.
Results
The final version of the Perfusionists\' Intraoperative Non-Technical Skills taxonomy contains 4 behavioral categories (decision making, situation awareness, task management and leadership, teamwork and communication) with 4 behavioral elements each. Categories and elements are rated using an 8-point Likert scale ranging from 0.5 to 4.0. A total of 60 perfusionist raters were included and the comparison between rating distribution on \"poor performance\" and \"good performance\" videos yielded a statistically significant difference between groups, with a P value less than .001. A similar difference was found in all behavioral categories and elements. Reliability analysis showed moderate inter-rater reliability across overall ratings (intraclass correlation coefficient, 0.735; 95% confidence interval, 0.674-0.796; P < .001). Similar inter-rater reliability was found when raters were stratified by experience level.
Conclusions
The Perfusionists\' Intraoperative Non-Technical Skills tool presented moderate inter-rater reliability among perfusionists with varied levels of experience. This tool can be used to train and assess perfusionists in relevant nontechnical skills, with the potential to enhance safety and improve surgical outcomes.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 01 Jul 2021; epub ahead of print
Dias RD, Riley W, Shann K, Likosky DS, Fitzgerald D, Yule S
J Thorac Cardiovasc Surg: 01 Jul 2021; epub ahead of print | PMID: 34261581
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Impact:
Abstract

Maximum standardized uptake value of the primary tumor does not improve candidate selection for sublobar resection.

Muraoka Y, Yoshida Y, Nakagawa K, Ito K, ... Motoi N, Yatabe Y
Objective
This retrospective study examined whether adding the maximum standardized uptake value of a primary tumor to the consolidation-to-tumor ratio from a high-resolution computed tomography scan can improve the predictive accuracy for pathological noninvasive lung cancer and lead to better patient selection for sublobar resection.
Methods
We included 926 patients with clinical stage IA non-small cell lung cancer. Pathological noninvasive cancer (n = 515) was defined as any case without lymphatic invasion, vascular invasion, or lymph node metastasis. The prediction accuracies of maximum standardized uptake value and consolidation-to-tumor ratio were evaluated using receiver operating characteristic curves and area under the curve.
Results
For consolidation-to-tumor ratio or maximum standardized uptake value alone, the area under the curves were 0.733 (95% confidence interval, 0.708-0.758) and 0.842 (95% confidence interval, 0.816-0.866), respectively. When the consolidation-to-tumor ratio and maximum standardized uptake value were combined, the area under the curve was 0.854 (95% confidence interval, 0.829-0.876). However, to obtain a predictive specificity of 97%, sensitivity needed to be 42.5% for the consolidation-to-tumor ratio, 38.3% for the maximum standardized uptake value, and 45.0% for these 2 in combination.
Conclusions
Our results suggest that despite the high area under the curve for maximum standardized uptake value, caution is needed when using maximum standardized uptake value to select candidates for sublobar resection. We found that a low maximum standardized uptake value did not mean the tumor was a pathological noninvasive lung cancer. Therefore, using consolidation-to-tumor ratios from high-resolution computed tomography to decide whether sublobar resection is appropriate for patients with clinical stage IA non-small cell lung cancer is better than using maximum standardized uptake value when setting specificity to a conservative 97% for predicting pathological noninvasive lung cancer.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 01 Jul 2021; epub ahead of print
Muraoka Y, Yoshida Y, Nakagawa K, Ito K, ... Motoi N, Yatabe Y
J Thorac Cardiovasc Surg: 01 Jul 2021; epub ahead of print | PMID: 34275620
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Impact:
Abstract

Sublobar resection is comparable to lobectomy for screen-detected lung cancer.

Kamel MK, Lee B, Harrison SW, Port JL, Altorki NK, Stiles BM
Objective
Sublobar resection is frequently offered to patients with small, peripheral lung cancers, despite the lack of outcome data from ongoing randomized clinical trials. Sublobar resection may be a particularly attractive surgical strategy for screen-detected lung cancers, which have been suggested to be less biologically aggressive than cancers detected by other means. Using prospective data collected from patients undergoing surgery in the National Lung Screening Trial, we sought to determine whether extent of resection affected survival for patients with screen-detected lung cancer.
Methods
The National Lung Screening Trial database was queried for patients who underwent surgical resection for confirmed lung cancer. Propensity score matching analysis (lobectomy vs sublobar resection) was done (nearest neighbor, 1:1, matching with no replacement, caliper 0.2). Demographics, clinicopathologic and perioperative outcomes, and long-term survival were compared in the entire cohort and in the propensity-matched groups. Multivariable logistic regression analysis was done to identify factors associated with increased postoperative morbidity or mortality.
Results
We identified 1029 patients who underwent resection for lung cancer in the National Lung Screening Trial, including 821 patients (80%) who had lobectomy and 166 patients (16%) who had sublobar resection, predominantly wedge resection (n = 114, 69% of sublobar resection). Patients who underwent sublobar resection were more likely to be female (53% vs 41%, P = .004) and had smaller tumors (1.5 cm vs 2 cm, P < .001). The sublobar resection group had fewer postoperative complications (22% vs 32%, P = .010) and fewer cardiac complications (4% vs 9%, P = .033). For stage I patients undergoing sublobar resection, there was no difference in 5-year overall survival (77% for both groups, P = .89) or cancer-specific survival (83% for both groups, P = .96) compared with patients undergoing lobectomy. On multivariable logistic regression analysis, sublobar resection was the only factor associated with lower postoperative morbidity/mortality (odds ratio, 0.63; 95% confidence interval, 0.40-0.98). To compare surgical strategies in balanced patient populations, we propensity matched 127 patients from each group undergoing sublobar resection and lobectomy. There were no differences in demographics or clinical and tumor characteristics among matched groups. There was again no difference in 5-year overall survival (71% vs 65%, P = .40) or cancer-specific survival (75% vs 73%, P = .89) for patients undergoing lobectomy and sublobar resection, respectively.
Conclusions
For patients with screen-detected lung cancer, sublobar resection confers survival similar to lobectomy. By decreasing perioperative complications and potentially preserving lung function, sublobar resection may provide distinct advantages in a screened patient cohort.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 30 Jun 2021; epub ahead of print
Kamel MK, Lee B, Harrison SW, Port JL, Altorki NK, Stiles BM
J Thorac Cardiovasc Surg: 30 Jun 2021; epub ahead of print | PMID: 34281703
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Abstract

Association of diameter and wall stresses of tricuspid aortic valve ascending thoracic aortic aneurysms.

Gomez A, Wang Z, Xuan Y, Hope MD, ... Ge L, Tseng EE
Objective
Ascending thoracic aortic aneurysms carry a risk of acute type A dissection. Elective repair guidelines are designed around size thresholds, but the 1-dimensional parameter of maximum diameter cannot predict acute events in small aneurysms. Biomechanically, dissection can occur when wall stress exceeds strength. Patient-specific ascending thoracic aortic aneurysm wall stresses may be a better predictor of dissection. Our aim was to compare wall stresses in tricuspid aortic valve-associated ascending thoracic aortic aneurysms based on diameter.
Methods
Patients with tricuspid aortic valve-associated ascending thoracic aortic aneurysm and diameter 4.0 cm or greater (n = 221) were divided into groups by 0.5-cm diameter increments. Three-dimensional geometries were reconstructed from computed tomography images, and finite element models were developed taking into account prestress geometries. A fiber-embedded hyperelastic material model was applied to obtain longitudinal and circumferential wall stress distributions under systolic pressure. Median stresses with interquartile ranges were determined. The Kruskal-Wallis test was used for comparisons between size groups.
Results
Peak longitudinal wall stresses for tricuspid aortic valve-associated ascending thoracic aortic aneurysm were 290 (265-323) kPa for size 4.0 to 4.4 cm versus 330 (296-359) kPa for 4.5 to 4.9 cm versus 339 (320-373) kPa for 5.0 to 5.4 cm versus 318 (293-351) kPa for 5.5 to 5.9 cm versus 373 (363-449) kPa for 6.0 cm or greater (P = 8.7e-8). Peak circumferential wall stresses were 460 (421-543) kPa for size 4.0 to 4.4 cm versus 503 (453-569) kPa for 4.5 to 4.9 cm versus 549 (430-588) kPa for 5.0 to 5.4 cm versus 540 (471-608) kPa for 5.5 to 5.9 cm versus 596 (506-649) kPa for 6.0 cm or greater (P = .0007).
Conclusions
Circumferential and longitudinal wall stresses are higher as diameter increases, but size groups had large overlap of stress ranges. Wall stress thresholds based on aneurysm wall strength may be a better predictor of patient-specific risk of dissection than diameter in small ascending thoracic aortic aneurysms.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 29 Jun 2021; epub ahead of print
Gomez A, Wang Z, Xuan Y, Hope MD, ... Ge L, Tseng EE
J Thorac Cardiovasc Surg: 29 Jun 2021; epub ahead of print | PMID: 34275618
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Abstract

Complete atrioventricular septal defect with absent or diminutive primum component: Incidence, anatomic characteristics, and outcomes.

Kwon MH, Schultz AH, Lee M, Permut LC, McMullan DM, Nuri MK
Background
Repair of complete atrioventricular septal defect with absent or diminutive primum defect is challenging because of atrial septal malposition and abnormal anatomy of the left atrioventricular valve. We sought to define the incidence, anatomy, and surgical outcomes of this entity.
Methods
We identified all patients in our institutional database presenting for complete atrioventricular septal defect repair from 2006 to 2018. Operative reports and echocardiograms were reviewed to determine the presence and size of the primum defect, atrioventricular valve anatomy, degree of atrioventricular valve regurgitation, repair method, and complications, including reoperation for atrioventricular valve regurgitation. Functionally univentricular patients and those receiving repair at an outside institution were excluded.
Results
Of 183 patients with complete atrioventricular septal defect, absent/diminutive primum defect occurred in 16 patients (8.7%; 10 absent, 6 diminutive). Six patients (38%) had leftward malposition of the atrium septum on the common atrioventricular valve. The rate of reoperation for left atrioventricular valve regurgitation was 31% (3 early, 2 late), for which preoperative predictors included leftward malposition of the atrial septum onto the common atrioventricular valve (4/6 patients with malposition required reoperation, P = .036, Fisher exact test). One patient exhibiting this risk factor died. The overall rate of moderate or greater left atrioventricular valve regurgitation on the most recent postoperative echocardiogram was 13% (2/16 patients; median follow-up, 141 days; range, 3-2236 days).
Conclusions
Complete atrioventricular septal defect with absent or diminutive primum defect is a unique variant of complete atrioventricular septal defect for which the risk of reoperation for left atrioventricular valve regurgitation after complete repair is high and risk factors include leftward malposition of the atrial septum on the common atrioventricular valve.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Jun 2021; epub ahead of print
Kwon MH, Schultz AH, Lee M, Permut LC, McMullan DM, Nuri MK
J Thorac Cardiovasc Surg: 25 Jun 2021; epub ahead of print | PMID: 34266667
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Abstract

Inhibition of mitochondrial reactive oxygen species improves coronary endothelial function after cardioplegic hypoxia/reoxygenation.

Song Y, Xing H, He Y, Zhang Z, ... Sellke FW, Feng J
Objective
Cardioplegic ischemia-reperfusion and diabetes mellitus are correlated with coronary endothelial dysfunction and inactivation of small conductance calcium-activated potassium channels. Increased reactive oxidative species, such as mitochondrial reactive oxidative species, may contribute to oxidative injury. Thus, we hypothesized that inhibition of mitochondrial reactive oxidative species may protect coronary small conductance calcium-activated potassium channels and endothelial function against cardioplegic ischemia-reperfusion-induced injury.
Methods
Small coronary arteries and endothelial cells from the hearts of mice with and without diabetes mellitus were isolated and examined by using a cardioplegic hypoxia and reoxygenation model to determine whether the mitochondria-targeted antioxidant Mito-Tempo could protect against coronary endothelial and small conductance calcium-activated potassium channel dysfunction. The microvessels or mouse heart endothelial cells were treated with or without Mito-Tempo (0-10 μM) 5 minutes before and during cardioplegic hypoxia and reoxygenation. Microvascular function was assessed in vitro by vessel myography. K+ currents of mouse heart endothelial cells were measured by whole-cell patch clamp. The levels of intracellular cytosolic free calcium (Ca2+) concentration, mitochondrial reactive oxidative species, and small conductance calcium-activated potassium protein expression of mouse heart endothelial cells were measured by Rhod-2 fluorescence staining, MitoSox, and Western blotting, respectively.
Results
Cardioplegic hypoxia and reoxygenation significantly attenuated endothelial small conductance calcium-activated potassium channel activity, caused calcium overload, and increased mitochondrial reactive oxidative species of mouse heart endothelial cells in both the nondiabetic and diabetes mellitus groups. In addition, treating mouse heart endothelial cells with Mito-Tempo (10 μM) reduced cardioplegic hypoxia and reoxygenation-induced Ca2+ and mitochondrial reactive oxidative species overload in both the nondiabetic and diabetes mellitus groups, respectively (P < .05). Treatment with Mito-Tempo (10 μM) significantly enhanced coronary relaxation responses to adenosine 5\'-diphosphate and NS309 (P < .05), and endothelial small conductance calcium-activated potassium channel currents in both the nondiabetic and diabetes mellitus groups (P < .05).
Conclusions
Administration of Mito-Tempo improves endothelial function and small conductance calcium-activated potassium channel activity, which may contribute to its enhancement of endothelium-dependent vasorelaxation after cardioplegic hypoxia and reoxygenation.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Jun 2021; epub ahead of print
Song Y, Xing H, He Y, Zhang Z, ... Sellke FW, Feng J
J Thorac Cardiovasc Surg: 25 Jun 2021; epub ahead of print | PMID: 34274141
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Abstract

Myeloperoxidase in the pericardial fluid improves the performance of prediction rules for postoperative atrial fibrillation.

Liu Y, Yu M, Wu Y, Wu F, Feng X, Zhao H
Objectives
After surgery, inflammation is a prominent factor influencing postoperative atrial fibrillation. Myeloperoxidase is a major contributor to inflammatory responses after surgical tissue damage. We evaluated whether myeloperoxidase is associated with postoperative atrial fibrillation clinically and in an animal model.
Methods
This prospective cohort study included patients undergoing isolated coronary artery bypass grafting. Myeloperoxidase concentrations in blood and pericardial fluid were determined at baseline and 6, 12, and 18 hours after coronary artery bypass grafting. Myeloperoxidase activity in blood, pericardial fluid, and atrium were also evaluated in a canine coronary artery bypass grafting model. Electrophysiologic, histologic, and immunohistochemistry analyses were performed to explore underlying mechanisms.
Results
Postoperative atrial fibrillation occurred in 45 of 137 patients (32.8%). Patients with postoperative atrial fibrillation had significantly higher serum and pericardial myeloperoxidase levels. Individual clinical and surgical factors had moderate predictive value (area under the curve, 0.760) for postoperative atrial fibrillation. Discrimination improved remarkably when myeloperoxidase was combined with other parameters (area under the curve, 0.901). Pericardial myeloperoxidase at 6 hours postoperatively was the strongest independent predictor of postoperative atrial fibrillation (odds ratio, 19.215). The rate of postoperative atrial fibrillation increased exponentially across pericardial myeloperoxidase grades. Compared with controls, coronary artery bypass grafting-treated dogs showed higher atrial fibrillation vulnerability and maintenance, shorter atrial effective refractory period, attenuated connexin 43 expression, and increased myocardial and pericardial myeloperoxidase activity. Connexin 43 expression and atrial effective refractory period were strongly negatively correlated with myocardial and pericardial myeloperoxidase activity.
Conclusions
Myeloperoxidase is linked to postoperative atrial fibrillation, and the ability to predict postoperative atrial fibrillation was remarkably improved by adding pericardial myeloperoxidase. Myeloperoxidase-related atrial structural and electrical remodeling is a physiologic substrate for this arrhythmia.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Jun 2021; epub ahead of print
Liu Y, Yu M, Wu Y, Wu F, Feng X, Zhao H
J Thorac Cardiovasc Surg: 21 Jun 2021; epub ahead of print | PMID: 34275621
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This program is still in alpha version.