Journal: J Thorac Cardiovasc Surg

Sorted by: date / impact
Abstract

Congenital aortic and truncal valve reconstruction using the Ozaki technique: Short-term clinical results.

Baird CW, Cooney B, Chávez M, Sleeper LA, Marx GR, Del Nido PJ
Objectives
Aortic valve reconstruction (AVRec) with neocuspidization or the Ozaki procedure with complete cusp replacement for aortic valve disease has excellent mid-term results in adults. Limited results of AVRec in pediatric patients have been reported. We report our early outcomes of the Ozaki procedure for congenital aortic and truncal valve disease.
Methods
A retrospective analysis was performed on all 57 patients with congenital aortic and truncal valve disease who had a 3-leaflet Ozaki procedure at a single institution from August 2015 to February 2019. Outcome measures included mortality, surgical or catheter-based reinterventions, and echocardiographic measurements.
Results
Twenty-four patients had aortic regurgitation (AR), 6 had aortic stenosis (AS), and 27 patients had AS/AR. Two patients had quadricuspid valves, 26 had tricuspid, 20 had bicuspid, and 9 had unicusp aortic valves. Four patients had truncus arteriosus. Thirty-four patients had previous aortic valve repairs and 5 had replacements. Preoperative echocardiography mean annular diameter was 20.90 ± 4.98 cm and peak gradient for patients with AS/AR was 53.62 ± 22.20 mm Hg. Autologous, Photofix, and CardioCel bovine pericardia were used in 20, 35, and 2 patients. Eight patients required aortic root enlargement and 20 had sinus enlargement. Fifty-one patients had concomitant procedures. Median intensive care unit and hospital length of stay were 1.87 and 6.38 days. There were no hospital mortalities or early conversions to valve replacement. At discharge, 98% of patients had mild or less regurgitation and peak aortic gradient was 16.9 ± 9.5 mm Hg. Two patients underwent aortic valve replacement. At median follow-up of 8.1 months, 96% and 91% of patients had less than moderate regurgitation and stenosis, respectively.
Conclusions
The AVRec procedure has acceptable short-term results and should be considered for valve reconstruction in pediatric patients with congenital aortic and truncal valve disease. Longer-term follow-up is necessary to determine the optimal patch material and late valve function and continued annular growth.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 29 Apr 2021; 161:1567-1577
Baird CW, Cooney B, Chávez M, Sleeper LA, Marx GR, Del Nido PJ
J Thorac Cardiovasc Surg: 29 Apr 2021; 161:1567-1577 | PMID: 33612305
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Impact:
Abstract

United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance.

Enumah ZO, Bolman RM, Zilla P, Boateng P, ... Dearani J, Higgins R
Background
Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients.
Methods
As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites.
Results
The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).
Conclusions
Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.

Copyright © 2021 Jointly between The Society of Thoracic Surgeons, The American Association for Thoracic Surgery, the European Association for Cardio-Thoracic Surgery and SAGE Publications Ltd. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 30 May 2021; 161:2108-2113
Enumah ZO, Bolman RM, Zilla P, Boateng P, ... Dearani J, Higgins R
J Thorac Cardiovasc Surg: 30 May 2021; 161:2108-2113 | PMID: 33840466
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Abstract

Endovascular repair of intercostal and visceral aortic patch aneurysms following open thoracoabdominal aortic aneurysm repair.

Trans-Atlantic Aortic Research Consortium Investigators
Purpose
Reoperative open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAAs) is associated with high morbidity and mortality. The aim of this study was to analyze outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) for the treatment of intercostal or visceral aortic patch aneurysms after OSR of TAAAs.
Methods
We reviewed the clinical data and outcomes of consecutive patients treated at 8 academic centers by F-BEVAR for visceral and intercostal aortic patch aneurysms after OSR of TAAAs (2011-2019). All patients had involvement of at least one target vessel requiring incorporation by a fenestration or directional branch. End points were technical success, 30-day and/in-hospital mortality, major adverse events, patient survival, target vessel patency/instability, and freedom from reintervention.
Results
There were 29 patients with a median age of 70 (interquartile range, 63-74) years. Seven patients (24%) had connective tissue disorders. Technical success was 100%. There were no 30-day/in-hospital mortalities. Major adverse events occurred in 5 patients (17%), including estimated blood loss >1 L in 3 patients (10%), acute kidney injury and respiratory failure in 2 patients (7%) each, and transient paraparesis in 1 patient (3%). Median follow-up was 14 (interquartile range, 7-37) months. At 2 years, primary and secondary patency, freedom from target artery instability, freedom from reintervention, and patient survival were 95%, 100%, 83%, 61%, and 96%, respectively.
Conclusions
F-BEVAR could be considered as an alternative to reoperative OSR in patients with visceral or intercostal aortic patch aneurysms. This series showed no mortality and a low rate of major adverse events, but a significant need for reintervention.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 29 Apr 2021; epub ahead of print
Trans-Atlantic Aortic Research Consortium Investigators
J Thorac Cardiovasc Surg: 29 Apr 2021; epub ahead of print | PMID: 34030882
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Impact:
Abstract

Intervention rates and outcomes in medically managed uncomplicated descending thoracic aortic dissections.

Kreibich M, Siepe M, Berger T, Beyersdorf F, ... Czerny M, Rylski B
Objective
To evaluate the long-term incidence and outcome of aortic interventions for medically managed uncomplicated thoracic aortic dissections.
Methods
Between January 2012 and December 2018, 91 patients were discharged home with an uncomplicated, medically treated aortic dissection (involving the descending aorta with or without aortic arch involvement, no ascending involvement). After a median period of 4 (first quartile: 2, third quartile: 11) months, 30 patients (33%) required an aortic intervention. Patient characteristics, radiographic, treatment, and follow-up data were compared for patients with and without aortic interventions. A competing risk regression model was analyzed to identify independent predictors of aortic intervention and to predict the risk for intervention.
Results
Patients who underwent aortic interventions had significantly larger thoracic (P = .041) and abdominal (P = .015) aortic diameters, the dissection was significantly longer (P = .035), there were more communications between both lumina (P = .040), and the first communication was significantly closer to the left subclavian artery (P = .049). A descending thoracic aortic diameter exceeding 45 mm was predictive for an aortic intervention (P = .001; subdistribution hazard ratio: 3.51). The risk for aortic intervention was 27% ± 10% and 36% ± 11% after 1 and 3 years, respectively. Fourteen patients (47%) underwent thoracic endovascular aortic repair, 11 patients (37%) thoracic endovascular aortic repair and left carotid to subclavian bypass, 3 patients (10%) total arch replacement with the frozen elephant trunk technique, and 2 patients (7%) thoracoabdominal aortic replacement. We observed no in-hospital mortality.
Conclusions
The need for secondary aortic interventions in patients with initially medically managed, uncomplicated descending aortic dissections is substantial. The full spectrum of aortic treatment options (endovascular, hybrid, conventional open surgical) is required in these patients.

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

J Thorac Cardiovasc Surg: 26 Apr 2021; epub ahead of print
Kreibich M, Siepe M, Berger T, Beyersdorf F, ... Czerny M, Rylski B
J Thorac Cardiovasc Surg: 26 Apr 2021; epub ahead of print | PMID: 34001355
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Impact:
Abstract

Factors associated with mortality or transplantation versus Fontan completion after cavopulmonary shunt for patients with tricuspid atresia.

Callahan CP, Jegatheeswaran A, Barron DJ, Husain SA, ... McCrindle BW, Congenital Heart Surgeons\' Society Tricuspid Atresia Working Group
Objective
Tricuspid atresia with normally related great vessels (TA) is considered the optimal substrate for the Fontan pathway. The factors associated with death or transplantation after cavopulmonary shunt (CPS) are underappreciated. We aimed to determine factors associated with CPS-Fontan interstage death/transplantation versus transition to Fontan in TA.
Methods
A total of 417 infants younger than 3 months of age with TA were enrolled (January 1999 to February 2020) from 40 institutions into the Congenital Heart Surgeons\' Society TA cohort. Parametric competing risk methodology was used to determine factors associated with the competing end points of death/transplantation without Fontan completion, and transition to Fontan.
Results
CPS was performed in 382 patients with TA; of those, 5% died or underwent transplantation without transition to Fontan and 91% transitioned to Fontan by 5 years after CPS. Prenatal diagnosis (hazard ratio [HR], 0.74; P < .001) and pulmonary artery band (PAB) at CPS (HR, 0.50; P < .001) were negatively associated with Fontan completion. Preoperative moderate or greater mitral valve regurgitation (HR, 3.0; P < .001), concomitant mitral valve repair (HR, 11.0; P < .001), PAB at CPS (HR, 3.0; P < .001), postoperative superior vena cava interventions (HR, 9.0; P < .001), and CPS takedown (HR, 40.0; P < .001) were associated with death/transplantation.
Conclusions
The mortality rate after CPS in patients with TA is notable. Those with preoperative mitral valve regurgitation remain a high-risk group. PAB at the time of CPS being associated with both increased risk of death and decreased Fontan completion may represent a deleterious effect of antegrade pulmonary blood flow in the CPS circulation.

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

J Thorac Cardiovasc Surg: 29 Apr 2021; epub ahead of print
Callahan CP, Jegatheeswaran A, Barron DJ, Husain SA, ... McCrindle BW, Congenital Heart Surgeons' Society Tricuspid Atresia Working Group
J Thorac Cardiovasc Surg: 29 Apr 2021; epub ahead of print | PMID: 34045062
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Impact:
Abstract

Difference in spontaneous myocardial infarction and mortality in percutaneous versus surgical revascularization trials: A systematic review and meta-analysis.

Gaudino M, Di Franco A, Spadaccio C, Rahouma M, ... Fremes S, Doenst T
Objectives
It has been hypothesized that the survival benefit of coronary artery bypass (CABG) compared with percutaneous interventions (PCI) may be associated with the reduction in spontaneous myocardial infarction (SMI) achieved by surgery. This, however, has not been formally investigated. The present meta-analysis aims to evaluate the association between the difference in SMI and in survival in PCI versus CABG randomized controlled trials (RCTs).
Methods
A systematic search was performed to identify all RCTs comparing PCI with CABG for the treatment of coronary artery disease and reporting SMI outcomes. Generic inverse variance method was used to pool outcomes as natural logarithms of the incident rate ratios across studies. Subgroup analysis and interaction test were used to compare the difference of the primary outcome among trials that did and did not report a significant reduction in SMI- in the patients treated by CABG. Primary outcome was all-cause mortality; secondary outcome was SMI.
Results
Twenty RCTs were included in the meta-analysis. A statistically significant difference in SMI in favor of CABG was found in 7 of the included trials (35%). Overall, PCI was associated with significantly greater all-cause mortality (incident rate ratio, 1.13; 95% confidence interval, 1.01-1.28). At subgroup analysis, a significant difference in survival in favor of CABG was seen only in trials that reported a significant reduction in SMI in the surgical arm (P for interaction 0.02).
Conclusions
In the published PCI versus CABG trials, the reduction in all-cause mortality in the surgical arm is associated with the protective effect of CABG against SMI.

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

J Thorac Cardiovasc Surg: 28 Apr 2021; epub ahead of print
Gaudino M, Di Franco A, Spadaccio C, Rahouma M, ... Fremes S, Doenst T
J Thorac Cardiovasc Surg: 28 Apr 2021; epub ahead of print | PMID: 34045061
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Abstract

Biventricular conversion after Fontan completion: A preliminary experience.

Doulamis IP, Marathe SP, Piekarski B, Beroukhim RS, ... Del Nido PJ, Emani SM
Objective
To assess the feasibility and outcomes of biventricular conversion following takedown of Fontan circulation.
Methods
Retrospective analysis of patients who had takedown of Fontan circulation and conversion to biventricular circulation at a single center from September 2007 to April 2020. Failing Fontan physiology was defined as Fontan circulation pressure >15 mm Hg and/or the presence of associated complications.
Results
Biventricular conversion was performed in 23 patients at a median age of 10.0 (7.5-13.0) years. Indications included failing Fontan physiology in 15 (65%) and elective takedown in 8 (35%) patients. A subset of patients (n = 6) underwent procedures for staged recruitment of the nondominant ventricle before conversion. Median z score of end-diastolic volume of borderline ventricle before takedown was -2.3 (-3.3, -1.3). Hypoplastic left heart syndrome (P < .01) and sub-/aortic stenosis (P < .01) were more common in these patients. Biventricular conversion with or without staged ventricular recruitment led to a significant increase in indexed end-diastolic volume (P < .01), indexed end-systolic volume (P < .01), and ventricular mass (P < .01) of the nondominant ventricle (14 right, 9 left ventricle). There were 5 (22%) deaths (1 [4%] early death). All who underwent elective biventricular conversion survived, whereas 2-year survival rate for patients with a failing Fontan circulation was 72.7% (95% confidence interval, 37%-90%). The overall, 3-year reoperation-free survival was 86.7% (95% confidence interval, 56%-96%). Left dominant atrioventricular canal defect (P < .01) and early era of biventricular conversion (P = .02) were significant predictors for mortality.
Conclusions
A primary as well as a staged biventricular conversion is feasible in patients who have had previous Fontan procedure. Although this provides an alternative to transplantation in patients with failing Fontan, outcomes are worse in those with failing Fontan compared with elective takedown of Fontan circulation. Optimal timing needs further evaluation.

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

J Thorac Cardiovasc Surg: 03 May 2021; epub ahead of print
Doulamis IP, Marathe SP, Piekarski B, Beroukhim RS, ... Del Nido PJ, Emani SM
J Thorac Cardiovasc Surg: 03 May 2021; epub ahead of print | PMID: 34045059
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Impact:
Abstract

Value of psychosocial evaluation for left ventricular assist device candidates.

Olt CK, Thuita LW, Soltesz EG, Tong MZ, ... Hsich EM, Stanford Integrated Psychosocial Assessment for Transplant Research Group
Objective
Left ventricular assist devices require a psychosocial assessment to determine candidacy despite limited data correlating with outcome. Our objective is to determine whether the Stanford Integrated Psychosocial Assessment for Transplant, a tool validated for transplant and widely used by left ventricular assist device programs, predicts left ventricular assist device program hospital readmissions and death.
Methods
We performed a retrospective analysis of adults at the Cleveland Clinic with Stanford Integrated Psychosocial Assessment for Transplant scores before primary left ventricular assist device program implantation from April 1, 2013, to December 31, 2018. The primary outcome was unplanned hospital readmissions censored at death, transplantation, and transfer of care. The secondary outcome was death.
Results
There were 263 patients in the left ventricular assist device program with a median (Q1, Q3) Stanford Integrated Psychosocial Assessment for Transplant score of 16 (8, 28). During a median follow-up 1.2 years, 56 died, 65 underwent transplantation, and 21 had transferred care. There were 640 unplanned hospital readmissions among 250 patients with at least 1 outpatient visit at our center. In a multivariable analysis, Stanford Integrated Psychosocial Assessment for Transplant components but not total Stanford Integrated Psychosocial Assessment for Transplant score was associated with readmissions. Psychopathology (Stanford Integrated Psychosocial Assessment for Transplant C-IX) was associated with hemocompatibility (coefficient 0.21 ± standard error 0.11, P = .040) and cardiac (0.15 ± 0.065, P = .02) readmissions. Patient readiness was associated with noncardiac (Stanford Integrated Psychosocial Assessment for Transplant A-III, 0.24 ± 0.099, P = .016) and cardiac (Stanford Integrated Psychosocial Assessment for Transplant A-low total, 0.037 ± 0.014, P = .007) readmissions. Poor living environment (Stanford Integrated Psychosocial Assessment for Transplant B-VIII) was associated with device-related readmissions (0.83 ± 0.34, P = .014). Death was associated with organic psychopathology or neurocognitive impairment (Stanford Integrated Psychosocial Assessment for Transplant C-X, 0.59 ± 0.21, P = .006).
Conclusions
Total Stanford Integrated Psychosocial Assessment for Transplant score was not associated with left ventricular assist device program readmission or mortality. However, we identified certain Stanford Integrated Psychosocial Assessment for Transplant components that were associated with outcome and could be used to create a left ventricular assist device program specific psychosocial tool.

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

J Thorac Cardiovasc Surg: 28 Apr 2021; epub ahead of print
Olt CK, Thuita LW, Soltesz EG, Tong MZ, ... Hsich EM, Stanford Integrated Psychosocial Assessment for Transplant Research Group
J Thorac Cardiovasc Surg: 28 Apr 2021; epub ahead of print | PMID: 34053742
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Impact:
Abstract

Outcomes of surgical aortic valve replacement over three decades.

Çelik M, Durko AP, Bekkers JA, Oei FBS, Mahtab EAF, Bogers AJJC
Objective
The study objective was to analyze temporal changes in baseline and procedural characteristics and long-term survival of patients undergoing surgical aortic valve replacement over a 30-year period.
Methods
A retrospective analysis of patients undergoing surgical aortic valve replacement between 1987 and 2016 in the Erasmus Medical Center (Rotterdam, The Netherlands) was conducted. Patient baseline and procedural characteristics were analyzed in periods according to the date of surgical aortic valve replacement (period A: 1987-1996; B: 1997-2006; C: 2007-2016). Survival status was determined using the Dutch National Death Registry. Relative survival was obtained by comparing the survival after surgical aortic valve replacement with the survival of the age-, sex-, and year-matched general population.
Results
Between 1987 and 2016, 4404 patients underwent SAVR. From period A to C, the mean age increased from 63.9 ± 11.2 years to 66.2 ± 12.3 years (P < .001), and the prevalence of diabetes mellitus, hypertension, hypercholesterolemia, previous myocardial infarction, and previous stroke at baseline increased (P values for trend for all < .001). The prevalence of concomitant procedures increased from 42.4% in period A to 48.3% in period C (P = .004). Bioprosthesis use increased significantly (18.8% in period A vs 67.1% in period C, P < .001). Mean survival after surgical aortic valve replacement was 13.8 years. Relative survival at 20 years in the overall cohort was 60.4% (95% confidence interval, 55.9-65.2) and 73.8% (95% confidence interval, 67.1-81.1) in patients undergoing isolated primary surgical aortic valve replacement.
Conclusions
Patient complexity has been continuously increasing over the last 30 years, yet long-term survival after surgical aortic valve replacement remains high compared with the age-, sex-, and year-matched general population.

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

J Thorac Cardiovasc Surg: 27 Apr 2021; epub ahead of print
Çelik M, Durko AP, Bekkers JA, Oei FBS, Mahtab EAF, Bogers AJJC
J Thorac Cardiovasc Surg: 27 Apr 2021; epub ahead of print | PMID: 34053741
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Impact:
Abstract

Surgery for severe congenital heart diseases in children from developing nations.

Lacour-Gayet F, Gouton M, Bical O, Lucet V, Roussin R, Leca F
Background
Children with severe congenital heart disease (CHD) are rarely treated in developing countries and have very little to no chance to survive in their local environment. Mécénat Chirurgie Cardiaque (MCC) flies to France children with CHD from developing countries. This report focuses on the early, mid, and late outcomes of 531 children with severe CHD sent to MCC for surgery from 1996 to 2019.
Methods
The inclusion criteria were based on diagnosis and not on procedure. MCC is present in 66 countries and has developed a robust staff, including 12 permanent employees and 700 volunteers, with 350 host families based in France, 120 local correspondents, and 100 local physicians. Since 1996, MCC has organized a basic training of local pediatric cardiologists yearly, offering a free 1-month training course. Over time, MCC could count on a pool of doctors trained in basic pediatric cardiology. Flights were secured by the Aviation Sans Frontieres Foundation. Nine French centers performed the surgeries. A robust follow-up was conducted in all the nations where MCC operates.
Results
The most frequent pathologies were single ventricle (n = 126), double-outlet right ventricle (n = 116), pulmonary atresia with ventricular septal defect (n = 68), transposition of the great arteries with ventricular septal defect and transposition of the great arteries with intact ventricular septum (n = 61), arterial trunk (n = 39), transposition of the great arteries with ventricular septal defect and left ventricle outflow tract obstruction (n = 35), complete atrioventricular septal defect (n = 18), congenitally corrected transposition of the great arteries (n = 16), and so on. The median age was 5.4 years (range, 1 month-26 years). The mean perioperative mortality was 5.5% (29 out of 531) (95% confidence limit, 3.5%-7.4%). The follow-up was 91.3%, with a mean follow-up of 5.1 years. The global actuarial survival at 5, 10, and 15 years was, respectively, 85%, 83%, and 74%. There was a significant higher late mortality for patients surviving only with a Blalock-Taussig shunt (P = .001).
Conclusions
Operating on 531 children with severe CHD from developing nations was achieved with satisfactory early and long-term results. Children with severe CHD are rarely operated on in developing nations. Programs like MCC\'s offer a viable option to save these children born with severe CHD.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 13 May 2021; epub ahead of print
Lacour-Gayet F, Gouton M, Bical O, Lucet V, Roussin R, Leca F
J Thorac Cardiovasc Surg: 13 May 2021; epub ahead of print | PMID: 34053740
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Impact:
Abstract

Outcomes of procedural complications in transfemoral transcatheter aortic valve replacement.

Percy ED, Harloff M, Hirji S, Tartarini RJ, ... Cherkasky O, Kaneko T
Objectives
As the application of transcatheter aortic valve replacement (TAVR) expands, the longitudinal implications of periprocedural complications are increasingly relevant. We examine the influence of TAVR complications on midterm survival.
Methods
Patients undergoing transfemoral TAVR at our institution between November 2011 and June 2018 were reviewed. Stroke severity was classified according to the National Institutes of Health stroke score. Kaplan-Meier analysis was used to assess survival, and a Cox proportional hazards model was created to examine independent associations with survival. The median follow-up time was 36 months for a total of 2789 patient-years.
Results
Overall, 866 patients were included. The mean age was 80 ± 9.5 years and mean Society of Thoracic Surgeons score was 4.8% ± 2.7%. The mortality rate at 30-days was 2.8% and 11.8% at 1 year. In-hospital left bundle branch block and 30-day permanent pacemaker insertion occurred in 14.8% and 7.9%, respectively. Postprocedural greater-than-mild paravalvular leak was present in 4.4% and stroke occurred in 3.8% at 30-days. Greater-than-mild paravalvular leak was associated with decreased survival at 2 years (P = .02), but not at 5 years. Severe stroke was independently associated with decreased survival at 5 years (hazard ratio, 5.73; 95% confidence interval, 2.29-14.36; P ≤ .001); however, the effect of nonsevere stroke did not reach significance (hazard ratio, 1.69; 95% confidence interval, 0.82-3.47; P = .152).
Conclusions
Severe stroke was independently associated with decreased 5-year survival and initial risks associated with paravalvular leak may be attenuated over the midterm following transfemoral TAVR. Strategies to minimize the incidence of stroke and paravalvular leak must be prioritized to improve longitudinal outcomes after TAVR.

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

J Thorac Cardiovasc Surg: 03 May 2021; epub ahead of print
Percy ED, Harloff M, Hirji S, Tartarini RJ, ... Cherkasky O, Kaneko T
J Thorac Cardiovasc Surg: 03 May 2021; epub ahead of print | PMID: 34053738
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Impact:
Abstract

Protective effects of hydrogen gas against spinal cord ischemia-reperfusion injury.

Kimura A, Suehiro K, Mukai A, Fujimoto Y, ... Yamada T, Mori T
Objective
This experimental study aimed to assess the efficacy of hydrogen gas inhalation against spinal cord ischemia-reperfusion injury and reveal its mechanism by measuring glutamate concentration in the ventral horn using an in vivo microdialysis method.
Methods
Male Sprague-Dawley rats were divided into the following 6 groups: sham, only spinal ischemia, 3% hydrogen gas (spinal ischemia + 3% hydrogen gas), 2% hydrogen gas (spinal ischemia + 2% hydrogen gas), 1% hydrogen gas (spinal ischemia + 1% hydrogen gas), and hydrogen gas dihydrokainate (spinal ischemia + dihydrokainate [selective inhibitor of glutamate transporter-1] + 3% hydrogen gas). Hydrogen gas inhalation was initiated 10 minutes before the ischemia. For the hydrogen gas dihydrokainate group, glutamate transporter-1 inhibitor was administered 20 minutes before the ischemia. Immunofluorescence was performed to assess the expression of glutamate transporter-1 in the ventral horn.
Results
The increase in extracellular glutamate induced by spinal ischemia was significantly suppressed by 3% hydrogen gas inhalation (P < .05). This effect was produced in increasing order: 1%, 2%, and 3%. Conversely, the preadministration of glutamate transporter-1 inhibitor diminished the suppression of spinal ischemia-induced glutamate increase observed during the inhalation of 3% hydrogen gas. Immunofluorescence indicated the expression of glutamate transporter-1 in the spinal ischemia group was significantly decreased compared with the sham group, which was attenuated by 3% hydrogen gas inhalation (P < .05).
Conclusions
Our study demonstrated hydrogen gas inhalation exhibits a protective and concentration-dependent effect against spinal ischemic injury, and glutamate transporter-1 has an important role in the protective effects against spinal cord injury.

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

J Thorac Cardiovasc Surg: 03 May 2021; epub ahead of print
Kimura A, Suehiro K, Mukai A, Fujimoto Y, ... Yamada T, Mori T
J Thorac Cardiovasc Surg: 03 May 2021; epub ahead of print | PMID: 34090694
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Impact:
Abstract

Long-term outcomes of atrioventricular septal defect and single ventricle: A multicenter study.

Arrigoni SC, IJsselhof R, Postmus D, Vonk JM, ... Schoof PH, Ebels T
Objective
The study objective was to analyze survival and incidence of Fontan completion of patients with single-ventricle and concomitant unbalanced atrioventricular septal defect.
Methods
Data from 4 Dutch and 3 Belgian institutional databases were retrospectively collected. A total of 151 patients with single-ventricle atrioventricular septal defect were selected; 36 patients underwent an atrioventricular valve procedure (valve surgery group). End points were survival, incidence of Fontan completion, and freedom from atrioventricular valve reoperation.
Results
Median follow-up was 13.4 years. Cumulative survival was 71.2%, 70%, and 68.5% at 10, 15, and 20 years, respectively. An atrioventricular valve procedure was not a risk factor for mortality. Patients with moderate-severe or severe atrioventricular valve regurgitation at echocardiographic follow-up had a significantly worse 15-year survival (58.3%) compared with patients with no or mild regurgitation (89.2%) and patients with moderate regurgitation (88.6%) (P = .033). Cumulative incidence of Fontan completion was 56.5%, 71%, and 77.6% at 5, 10, and 15 years, respectively. An atrioventricular valve procedure was not associated with the incidence of Fontan completion. In the valve surgery group, freedom from atrioventricular valve reoperation was 85.7% at 1 year and 52.6% at 5 years.
Conclusions
The long-term survival and incidence of Fontan completion in our study were better than previously described for patients with single-ventricle atrioventricular septal defect. A concomitant atrioventricular valve procedure did not increase the mortality rate or decrease the incidence of Fontan completion, whereas patients with moderate-severe or severe valve regurgitation at follow-up had a worse survival. Therefore, in patients with single-ventricle atrioventricular septal defect when atrioventricular valve regurgitation exceeds a moderate degree, the atrioventricular valve should be repaired.

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

J Thorac Cardiovasc Surg: 17 May 2021; epub ahead of print
Arrigoni SC, IJsselhof R, Postmus D, Vonk JM, ... Schoof PH, Ebels T
J Thorac Cardiovasc Surg: 17 May 2021; epub ahead of print | PMID: 34099273
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Impact:
Abstract

Interhospital variability in health care-associated infections and payments after durable ventricular assist device implant among Medicare beneficiaries.

Likosky DS, Yang G, Zhang M, Malani PN, ... Pagani FD, Michigan Congestive Heart Failure Investigators
Objective
The objective of this study was to investigate variations across hospitals in infection rates and associated costs, the latter reflected in 90-day Medicare payments. Despite high rates and expenditures of health care--associated infections associated with durable ventricular assist device implantation, few studies have examined interhospital variation and associated costs.
Methods
Clinical data on 8688 patients who received primary durable ventricular assist devices from July 2008 to July 2017 from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) hospitals (n = 120) were merged with postimplantation 90-day Medicare claims. Terciles of hospital-specific, risk-adjusted infection rates per 100 patient-months were estimated using Intermacs and associated with Medicare payments (among 5440 Medicare beneficiaries). Primary outcomes included infections within 90 days of implantation and Medicare payments.
Results
There were 3982 infections identified among 27.8% (2417/8688) of patients developing an infection. The median (25th, 75th percentile) adjusted incidence of infections (per 100 patient-months) across hospitals was 14.3 (9.3, 19.5) and varied according to hospital (range, 0.0-35.6). Total Medicare payments from implantation to 90 days were 9.0% (absolute difference: $13,652) greater in high versus low infection tercile hospitals (P < .0001). The period between implantation to discharge accounted for 73.1% of the difference in payments during the implantation to 90-day period across terciles.
Conclusions
Health care--associated infection rates post durable ventricular assist device implantation varied according to hospital and were associated with increased 90-day Medicare expenditures. Interventions targeting preventing infections could improve the value of durable ventricular assist device support from the societal and hospital perspectives.

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

J Thorac Cardiovasc Surg: 03 May 2021; epub ahead of print
Likosky DS, Yang G, Zhang M, Malani PN, ... Pagani FD, Michigan Congestive Heart Failure Investigators
J Thorac Cardiovasc Surg: 03 May 2021; epub ahead of print | PMID: 34099272
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Impact:
Abstract

Characteristics and outcomes of patients with COVID-19 supported by extracorporeal membrane oxygenation: A retrospective multicenter study.

Saeed O, Tatooles AJ, Farooq M, Schwartz G, ... Goldstein DJ, COVID-19 ECMO Working Group
Objective
To determine characteristics, outcomes, and clinical factors associated with death in patients with COVID-19 requiring extracorporeal membrane oxygenation (ECMO) support.
Methods
A multicenter, retrospective cohort study was conducted. The cohort consisted of adult patients (18 years of age and older) requiring ECMO in the period from March 1, 2020, to September 30, 2020. The primary outcome was in-hospital mortality after ECMO initiation assessed with a time to event analysis at 90 days. Multivariable Cox proportional regression was used to determine factors associated with in-hospital mortality.
Results
Overall, 292 patients from 17 centers comprised the study cohort. Patients were 49 (interquartile range, 39-57) years old and 81 (28%) were female. At the end of the follow-up period, 19 (6%) patients were still receiving ECMO, 25 (9%) were discontinued from ECMO but remained hospitalized, 135 (46%) were discharged or transferred alive, and 113 (39%) died during the hospitalization. The cumulative in-hospital mortality at 90 days was 42% (95% confidence interval [CI], 36%-47%). Factors associated with in-hospital mortality were age (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.06-1.61 per 10 years), renal dysfunction measured according to serum creatinine level (aHR, 1.21; 95% CI, 1.01-1.45), and cardiopulmonary resuscitation before ECMO placement (aHR, 1.87; 95% CI, 1.01-3.46).
Conclusions
In patients with severe COVID-19 necessitating ECMO support, in-hospital mortality occurred in fewer than half of the cases. ECMO might serve as a viable modality for terminally ill patients with refractory COVID-19.

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

J Thorac Cardiovasc Surg: 17 May 2021; epub ahead of print
Saeed O, Tatooles AJ, Farooq M, Schwartz G, ... Goldstein DJ, COVID-19 ECMO Working Group
J Thorac Cardiovasc Surg: 17 May 2021; epub ahead of print | PMID: 34112505
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Impact:
Abstract

A novel predictive model for poor in-hospital outcomes in patients with acute kidney injury after cardiac surgery.

Chen Z, Li J, Sun Y, Wang C, ... Yang K, Chen L
Objective
Patients with cardiac surgery-associated acute kidney injury are at risk of renal replacement therapy and in-hospital death. We aimed to develop and validate a novel predictive model for poor in-hospital outcomes among patients with cardiac surgery-associated acute kidney injury.
Methods
A total of 196 patients diagnosed with cardiac surgery-associated acute kidney injury were enrolled in this study as the training cohort, and 32 blood cytokines were measured. Least absolute shrinkage and selection operator regression and random forest quantile-classifier were performed to identify the key blood predictors for in-hospital composite outcomes (requiring renal replacement therapy or in-hospital death). The logistic regression model incorporating the selected predictors was validated internally using bootstrapping and externally in an independent cohort (n = 52).
Results
A change in serum creatinine (delta serum creatinine) and interleukin 16 and interleukin 8 were selected as key predictors for composite outcomes. The logistic regression model incorporating interleukin 16, interleukin 8, and delta serum creatinine yielded the optimal performance, with decent discrimination (area under the receiver operating characteristic curve: 0.947; area under the precision-recall curve: 0.809) and excellent calibration (Brier score: 0.056, Hosmer-Lemeshow test P = .651). Application of the model in the validation cohort yielded good discrimination. A nomogram was generated for clinical use, and decision curve analysis demonstrated that the new model adds more net benefit than delta serum creatinine.
Conclusions
We developed and validated a promising predictive model for in-hospital composite outcomes among patients with cardiac surgery-associated acute kidney injury and demonstrated interleukin-16 and interleukin-8 as useful predictors to improve risk stratification for poor in-hospital outcomes among those with cardiac surgery-associated acute kidney injury.

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

J Thorac Cardiovasc Surg: 10 May 2021; epub ahead of print
Chen Z, Li J, Sun Y, Wang C, ... Yang K, Chen L
J Thorac Cardiovasc Surg: 10 May 2021; epub ahead of print | PMID: 34112503
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Impact:
Abstract

Structural abnormalities after aortic root replacement with stentless xenograft.

Dagnegård HSH, Sigvardsen PE, Ihlemann N, Kofoed KF, ... Lund JT, Smerup MH
Objective
In complex and high-risk aortic root disease, the porcine Freestyle stentless bioprosthesis (Medtronic Inc, Minneapolis, Minn) is an important surgical treatment option. We aimed to determine prevalence and clinical effect of structural and functional abnormalities after full-root Freestyle implantation.
Methods
Our cross-sectional 2-center study combined with clinical follow-up included 253 patients with full-root Freestyle bioprostheses implanted from 1999 to 2017. Patients underwent transthoracic echocardiography (TTE) and contrast-enhanced, electrocardiogram-gated 4-dimensional cardiac computed tomography (4DCT) at median age 70 (interquartile range, 62-75) years. After 4DCT, clinical follow-up continued throughout 2018. Median follow-up was 3.3 years before 4DCT and 1.4 years after.
Results
We identified abnormalities in 46% of patients, including pseudoaneurysms (n = 32; 13%), moderate or severe coronary ostial stenosis (n = 54; 21%), and moderate-severe leaflet thickening or reduced leaflet motion (n = 51; 20%). TTE only identified 1 patient with pseudoaneurysm. After 4DCT, the unadjusted hazard ratio for surgical reintervention among patients with abnormal 4DCT was 4.2 (95% confidence interval, 1.2-15.3), in all, 10% required a reintervention. 4DCT abnormalities were associated with a statistically nonsignificant increased risk of death, stroke, or myocardial infarction (hazard ratio obtained using Cox proportional hazards regression analysis, 2.4; 95% confidence interval, 0.7-7.6). In all, 4.0% died, 3.6% had a myocardial infarction, and 2.0% had a stroke.
Conclusions
Structural and functional abnormalities of the aortic root are frequent after Freestyle implantation and TTE appears to be insufficient for follow-up. Abnormalities might be associated with increased risk of reintervention and potentially adverse clinical outcomes. Longer follow-up and larger study populations are needed to further clarify the clinical implications of abnormalities identified with 4DCT.

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

J Thorac Cardiovasc Surg: 11 May 2021; epub ahead of print
Dagnegård HSH, Sigvardsen PE, Ihlemann N, Kofoed KF, ... Lund JT, Smerup MH
J Thorac Cardiovasc Surg: 11 May 2021; epub ahead of print | PMID: 34116854
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Impact:
Abstract

Effect of sarcopenia on survival and spinal cord deficit outcomes after thoracoabdominal aortic aneurysm repair in patients 60 years of age and older.

Chatterjee S, Shi A, Yoon L, Green SY, ... LeMaire SA, Coselli JS
Objective
Sarcopenia (core muscle loss) has been used as a surrogate marker of frailty. We investigated whether sarcopenia would adversely affect survival after thoracoabdominal aortic aneurysm repair.
Methods
We retrospectively reviewed prospectively collected data from patients aged 60 years or older who underwent thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Imaging was reviewed by 2 radiologists blinded to clinical outcomes. The total psoas index was derived from total psoas muscle cross-sectional area (cm2) at the mid-L4 level, normalized for height (m2). Patients were divided by sex-specific total psoas index values into sarcopenia (lower third) and nonsarcopenia (upper two-thirds) groups. Multivariable modeling identified operative mortality and spinal cord injury predictors. Unadjusted and adjusted survival curves were analyzed.
Results
Of 392 patients identified, those with sarcopenia (n = 131) were older than nonsarcopenic patients (n = 261) (70.0 years vs 68.0 years; P = .02) and more frequently presented with aortic rupture or required urgent/emergency operations. Operative mortality was comparable (sarcopenia 13.7% vs nonsarcopenia 10.0%; P = .3); sarcopenia was not associated with operative mortality in the multivariable model (odds ratio, 1.40; 95% confidence interval, 0.73-2.77; P = .3). Sarcopenic patients experienced more frequent delayed (13.0% vs 4.6%; P = .005) and persistent (10.7% vs 3.4%; P = .008) paraplegia. Sarcopenia independently predicted delayed paraplegia (odds ratio, 3.17; 95% confidence interval, 1.42-7.08; P = .005) and persistent paraplegia (odds ratio, 3.29; 95% confidence interval, 1.33-8.13; P = .01) in the multivariable model. Adjusted for preoperative/operative covariates, midterm survival was similar for sarcopenic and nonsarcopenic patients (P = .3).
Conclusions
Sarcopenia did not influence early mortality or midterm survival after thoracoabdominal aortic aneurysm repair but was associated with greater risk for delayed and persistent paraplegia.

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

J Thorac Cardiovasc Surg: 03 Jun 2021; epub ahead of print
Chatterjee S, Shi A, Yoon L, Green SY, ... LeMaire SA, Coselli JS
J Thorac Cardiovasc Surg: 03 Jun 2021; epub ahead of print | PMID: 34147254
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Impact:
Abstract

Early implementation of renal replacement therapy after lung transplantation does not impair long-term kidney function in patients with idiopathic pulmonary arterial hypertension.

Benazzo A, Bajorek L, Morscher A, Schrutka L, ... Hoetzenecker K, Vienna Lung Transplantation Program
Objectives
In patients with idiopathic pulmonary arterial hypertension, cardiac function can be impaired in the early postoperative phase after lung transplantation because the chronically untrained left ventricle is prone to fail. Thus, restrictive fluid management is pivotal to unload the left heart. In our institution, continuous renal replacement therapy is implemented liberally whenever a patient cannot be balanced negatively. It remains unclear whether such strategy impairs long-term kidney function.
Methods
We retrospectively reviewed our institutional database for patients with idiopathic pulmonary arterial hypertension who underwent transplantation between 2000 and 2018. The impact of postoperative continuous renal replacement therapy on long-term outcomes was investigated using a linear mixed model and multivariable Cox regression.
Results
A total of 87 idiopathic pulmonary arterial hypertension lung transplant recipients were included in this analysis. In 38 patients (43%), continuous renal replacement therapy was started in the early postoperative period for a median of 16 days (10-22). In this group, urine production significantly decreased and patients began to acquire a positive fluid balance; however, homeostatic functions of the kidney were still preserved at the time of continuous renal replacement therapy initiation. All patients were successfully weaned from continuous renal replacement therapy and fully recovered their kidney function at the time of hospital discharge. No difference in kidney function was found between continuous renal replacement therapy and noncontinuous renal replacement therapy in patients within 5 years.
Conclusions
Early implementation of continuous renal replacement therapy for perioperative volume management does not impair long-term kidney function in idiopathic pulmonary arterial hypertension lung transplant recipients. Our data suggest that such a strategy leads to excellent long-term outcomes.

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

J Thorac Cardiovasc Surg: 31 May 2021; epub ahead of print
Benazzo A, Bajorek L, Morscher A, Schrutka L, ... Hoetzenecker K, Vienna Lung Transplantation Program
J Thorac Cardiovasc Surg: 31 May 2021; epub ahead of print | PMID: 34144824
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Impact:
Abstract

Impact of valve repair on mild tricuspid insufficiency in rheumatic mitral surgery.

Kim WK, Kim SE, Yoo JS, Jung JH, ... Jung SH, Lee JW
Objective
Tricuspid valve repair for mild tricuspid regurgitation during rheumatic mitral valve surgery is controversial. We evaluated the benefit of tricuspid valve repair for mild tricuspid regurgitation in rheumatic mitral valve surgery.
Methods
Among 1208 consecutive patients (52.6 ± 11.9 years) with mild tricuspid regurgitation who underwent rheumatic mitral valve surgery from 2000 to 2018 in 2 referral centers, 419 received concomitant tricuspid valve repair and 789 did not. The primary end point was the development of severe tricuspid regurgitation. Deaths were regarded as competing events. Secondary end points were death and heart failure. Inverse probability of treatment weighting was performed to reduce selection bias. Multivariable competing risk analysis was performed to determine the predictive factors of severe tricuspid regurgitation.
Results
There was no significant difference in early mortality rates between patients with and without tricuspid valve repair (P = .26). During a median follow-up of 71.6 (interquartile range: 25.3-124.2) months, the primary end point was detected in 7 of 419 patients (0.25%/patient-years) and 28 of 789 patients (0.57%/patient-years) with and without tricuspid valve repair, respectively (P = .04). There were no significant differences in the secondary end points. After baseline adjustment, the primary end point was not significantly different depending on the addition of tricuspid valve repair (hazard ratio, 0.64; 95% confidence interval, 0.23-1.77; P = .39). In multivariable analysis, only the omission of surgical atrial fibrillation ablation (hazard ratio, 4.52; 95% confidence interval, 2.07-9.87) was significantly associated with the development of severe tricuspid regurgitation.
Conclusions
Tricuspid valve repair for mild tricuspid regurgitation in rheumatic mitral valve surgery provides no overt clinical benefit.

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

J Thorac Cardiovasc Surg: 01 Jun 2021; epub ahead of print
Kim WK, Kim SE, Yoo JS, Jung JH, ... Jung SH, Lee JW
J Thorac Cardiovasc Surg: 01 Jun 2021; epub ahead of print | PMID: 34154801
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Impact:
Abstract

Comparison of SYNTAX score strata effects of percutaneous and surgical revascularization trials: A meta-analysis.

Gaudino M, Hameed I, Di Franco A, Naik A, ... Biondi-Zoccai G, Bangalore S
Objectives
The evidence supporting the use of the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score for risk stratification is controversial. We performed a systematic review and meta-analysis of all the randomized controlled trials comparing percutaneous coronary intervention versus coronary artery bypass grafting that reported their outcomes stratified by SYNTAX score, focusing on between-strata comparisons.
Methods
A systematic review of MEDLINE, EMBASE, Cochrane Library databases was performed. Incidence rate ratios were pooled with a random effect model. Between-group statistical heterogeneity according to accepted SYNTAX score tertiles was computed in the main analysis. Ratios of incidence rate ratios were computed to appraise between-strata effect, as sensitivity analysis. Primary and secondary outcomes were major adverse cardiac and cerebrovascular events and all-cause mortality, respectively. Separate sub-analyses were performed for left main and multivessel disease.
Results
From 425 citations, 6 trials were eventually included (8269 patients [4134 percutaneous coronary interventions, 4135 coronary artery bypass graftings]; mean follow-up: 6.2 years [range: 3.8-10]). Overall, percutaneous coronary intervention was associated with a significant increase in major adverse cardiac and cerebrovascular events (incidence rate ratio, 1.39, 95% confidence interval, 1.27-1.51) and nonsignificant increase in all-cause mortality (incidence rate ratio, 1.17, 95% confidence interval, 0.98-1.40). There was no significant statistical heterogeneity of treatment effect by SYNTAX score for major adverse cardiac and cerebrovascular events or mortality (P = .40 and P = .34, respectively). Results were consistent also for patients with left main and multivessel disease (major adverse cardiac and cerebrovascular events: P = .85 in left main, P = .78 in multivessel disease 0.78; mortality: P = .12 in left main; P = .34 in multivessel disease). Results of analysis based on ratios of incidence rate ratios were consistent with the main analysis.
Conclusions
No significant association was found between SYNTAX score and the comparative effectiveness of percutaneous coronary intervention and coronary artery bypass grafting. These findings have implications for clinical practice, future guidelines, and the design of percutaneous coronary intervention versus coronary artery bypass grafting trials.

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

J Thorac Cardiovasc Surg: 01 Jun 2021; epub ahead of print
Gaudino M, Hameed I, Di Franco A, Naik A, ... Biondi-Zoccai G, Bangalore S
J Thorac Cardiovasc Surg: 01 Jun 2021; epub ahead of print | PMID: 34176619
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Impact:
Abstract

Impact of preoperative glycometabolic status on outcomes in cardiac surgery: Systematic review and meta-analysis.

Corazzari C, Matteucci M, Kołodziejczak M, Kowalewski M, ... Barili F, Lorusso R
Background
Historically, impaired glucose metabolism has been associated with early and late complicated clinical outcomes after cardiac surgery; however, such a condition is not specific to subjects with diabetes mellitus and involves a larger patient population.
Methods
Databases were screened (January 2000 to December 2020) to identify eligible articles; studies that evaluated the association between preoperative metabolic status, as assessed by glycosylated hemoglobin levels and clinical outcomes, were considered. The studies were stratified in thresholds by baseline glycosylated hemoglobin level (lower vs higher).
Results
Thirty studies, involving 34,650 patients, were included in the review. In a meta-analysis stratified by glycosylated hemoglobin levels, early mortality was numerically reduced in each threshold comparison and yielded the highest reductions when less than 5.5% versus greater than 5.5% glycosylated hemoglobin levels were compared (risk ratio, 0.39; 95% confidence interval, 0.18-0.84; P = .02). Comparing higher glycosylated hemoglobin threshold values yielded comparable results. Late mortality was reduced with lower levels of glycosylated hemoglobin. Low preoperative glycosylated hemoglobin was associated with the lowest risk of sternal wound infections (risk ratio, 0.50; 95% confidence interval, 0.32-0.80; P = .003 and risk ratio, 0.53; 95% confidence interval, 0.39-0.70; P < .0001) for comparisons of less than 7.5% versus greater than 7.5% and less than 7.0% versus greater than 7.0% glycosylated hemoglobin thresholds, respectively. Additionally, levels of glycosylated hemoglobin lower than 7% were associated with reduced hospital stay, lower risk of stroke/transient ischemic attack (risk ratio 0.53; 95% confidence interval, 0.39-0.70; P < .0001), and acute kidney injury (risk ratio, 0.65; 95% confidence interval, 0.54-0.79; P < .0001).
Conclusions
Lower levels of glycosylated hemoglobin in patients undergoing cardiac surgery are associated with a lower risk of early and late mortality, as well as in the incidence of postoperative acute kidney injury, neurologic complications, and wound infection, compared with higher levels.

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

J Thorac Cardiovasc Surg: 31 May 2021; epub ahead of print
Corazzari C, Matteucci M, Kołodziejczak M, Kowalewski M, ... Barili F, Lorusso R
J Thorac Cardiovasc Surg: 31 May 2021; epub ahead of print | PMID: 34176617
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Impact:
Abstract

Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with Marfan syndrome.

Jiang X, Chen B, Jiang J, Shi Y, ... Fu W, Dong Z
Objective
To evaluate the mid-term outcomes of thoracic endovascular aorta repair (TEVAR) for Stanford type B aortic dissection (TBAD) in patients with Marfan syndrome (MFS).
Methods
Between January 2009 and December 2019, patients with MFS who underwent TEVAR for TBAD were enrolled. Demographic data, preoperative and perioperative clinical profiles, and follow-up data were collected and analyzed. The cumulative survival and freedom from reintervention rates were calculated with Kaplan-Meier analysis.
Results
A total of 26 patients were enrolled. The mean age was 38.5 ± 10.7 (range, 24-64 years). The in-hospital mortality was 0. The cumulative survival rate was 88.1% (95% confidence interval [CI], 67.5%-98.5%) at 5 years and 82.9% (95% CI, 60.2%-93.3%) at 10 years. Patients with a thrombosed false lumen (FL) along the length of the stent had a significantly higher cumulative survival rate (P < .05) and freedom from reintervention (P = .01) than patients with patent FL. The freedom from reintervention was 83.4% (95% CI, 61.4% to 93.4%) at 5 years and 50.3% (95% CI, 21.4%-97.3%) at 10 years. There was no significant difference freedom from reintervention in freedom from reintervention between patients with and those without a previous aortic root procedure (P = .46).
Conclusions
TEVAR can be performed safely and effectively for TBAD in patients with MFS. Perioperative mortality and morbidity were low; however, lifelong close follow-up in the clinic and imaging are mandatory to prevent aortic rupture. Patients with a patent FL were at high risk of late death.

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

J Thorac Cardiovasc Surg: 08 Jun 2021; epub ahead of print
Jiang X, Chen B, Jiang J, Shi Y, ... Fu W, Dong Z
J Thorac Cardiovasc Surg: 08 Jun 2021; epub ahead of print | PMID: 34176615
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Impact:
Abstract

Risk stratification of patients listed for heart transplantation while supported with extracorporeal membrane oxygenation.

Ivey-Miranda JB, Maulion C, Farrero-Torres M, Griffin M, ... Testani JM, Bellumkonda L
Objectives
Extracorporeal membrane oxygenation (ECMO) is used to support patients in severe cardiogenic shock. In the absence of recovery, these patients may need to be listed for heart transplant (HT), which offers the best long-term prognosis. However, posttransplantation mortality is significantly elevated in patients who receive ECMO. The objective of the present study was to describe and risk-stratify different profiles of patients listed for HT supported by ECMO.
Methods
Patients listed for HT in the United Network for Organ Sharing database were analyzed. The primary outcome was 1-year survival and was assessed in patients bridged to transplant with ECMO (ECMOBTT) and patients who were previously supported on ECMO but had it removed before HT (ECMOREMOVED).
Results
Among 65,636 adult candidates listed for HT (between 2001 and 2017), 712 were supported on ECMO, 292 of whom (41%) underwent HT (ECMOBTT, n = 202; ECMOREMOVED, n = 90). Most of the patients with ECMOREMOVED were transplanted with a ventricular assist device. In ECMOBTT, recipient age (each 10-year increase), time on the waitlist (both defined as minor risk factors), need for dialysis, and need for mechanical ventilation (both defined as major risk factors) were independent predictors of mortality. ECMOREMOVED and ECMOBTT with no risk factors showed 1-year survival comparable to that in patients who were never supported on ECMO. Compared with patients who were never on ECMO, patients in ECMOBTT group with minor risk factors, 1 major risk factor, and 2 major risk factors had ~2-, ~5-, and >10-fold greater 1-year mortality, respectively (P < .05).
Conclusions
The HT recipients in the ECMOREMOVED and ECMOBTT groups with no risk factors showed similar survival as the HT recipients who were never supported on ECMO. In the ECMOBTT group, posttransplantation mortality increased significantly with increasing risk factors.

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

J Thorac Cardiovasc Surg: 28 May 2021; epub ahead of print
Ivey-Miranda JB, Maulion C, Farrero-Torres M, Griffin M, ... Testani JM, Bellumkonda L
J Thorac Cardiovasc Surg: 28 May 2021; epub ahead of print | PMID: 34167814
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Impact:
Abstract

Geometry and flow in ascending aortic aneurysms are influenced by left ventricular outflow tract orientation: Detecting increased wall shear stress on the outer curve of proximal aortic aneurysms.

Salmasi MY, Pirola S, Mahuttanatan S, Fisichella SM, ... Xu XY, Athanasiou T
Background
The geometrical characterization of ascending thoracic aortic aneurysms in clinical practice is limited to diameter measurements. Despite growing interest in hemodynamic assessment, its relationship with ascending thoracic aortic aneurysm pathogenesis is poorly understood. This study examines the relationship between geometry of the ventriculo-aortic junction and blood flow patterns in ascending thoracic aortic aneurysm disease.
Methods
Thirty-three patients with ascending thoracic aortic aneurysms (exclusions: bicuspid aortic valves, connective tissue disease) underwent 4-dimensional flow magnetic resonance imaging. After image segmentation, geometrical parameters were measured, including aortic curvature, tortuosity, length, and diameter. A unique angular measurement made by the trajectory of the left ventricular outflow tract axis and the proximal aorta was also conducted. Velocity profiles were quantitatively and qualitatively analyzed. In addition, 11 patients (33%) underwent wall shear stress mapping of the ascending thoracic aortic aneurysm region using computational fluid dynamics simulation.
Results
Greater left ventricular outflow tract aortic angles were associated with larger aortic diameters at the levels of the sinus (coefficient = 0.387, P = .014) and ascending aorta (coefficient = 0.284, P = .031). Patients with left ventricular outflow tract aortic angles greater than 60° had marked asymmetric flow acceleration on the outer curvature in the proximal aorta, ascertained from 4-dimensional flow analysis. For patients undergoing computational fluid dynamics assessment, regression analysis found that higher left ventricular outflow tract aortic angles were associated with significantly higher wall shear stress values in the outer curve of the aorta (coefficient 0.07, 95% confidence interval 0.04-0.11, P = .002): Angles greater than 50° yielded time-averaged wall shear stress values greater than 2.5 Pa, exhibiting a linear relationship.
Conclusions
Our findings strengthen the hypothesis of flow-mediated ascending thoracic aortic aneurysm disease progression and that left ventricular outflow tract aortic angle may be a predictor of disease severity.

Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 15 Jun 2021; epub ahead of print
Salmasi MY, Pirola S, Mahuttanatan S, Fisichella SM, ... Xu XY, Athanasiou T
J Thorac Cardiovasc Surg: 15 Jun 2021; epub ahead of print | PMID: 34217540
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Impact:
Abstract

Comprehensive assessment of heart failure in patients with preserved ejection fraction undergoing coronary bypass grafting.

Lee SH, Choi KH, Song YB, Jeong DS, ... Kim WS, Lee YT
Objective
Although coronary artery bypass grafting is expected to improve the outcomes of patients with advanced coronary artery disease, whether prognosis is different according to preoperative diastolic function remains unclear. This study sought to evaluate the prognostic implications of preoperative heart failure with preserved ejection fraction in patients undergoing coronary artery bypass grafting.
Methods
A total of 3593 consecutive patients with preserved ejection fraction (≥50%) who underwent coronary artery bypass grafting between January 1, 2001, and December 31, 2017, were evaluated. According to Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, Final Etiology score, they were stratified into 3 groups: (1) non-heart failure with preserved ejection fraction (low-risk); (2) indeterminate (intermediate risk); and (3) heart failure with preserved ejection fraction (high risk). The primary outcome was all-cause death at 5 years after surgery.
Results
Among the study population, 984 patients (27.4%) had preoperative heart failure with preserved ejection fraction. After coronary artery bypass grafting, 30-day survival in the heart failure with preserved ejection fraction group did not differ significantly from that in the non-heart failure with preserved ejection fraction group. The 5-year survival of the heart failure with preserved ejection fraction group was significantly lower than that of the non-heart failure with preserved ejection fraction group (91.9% vs 97.0%; adjusted hazard ratio, 2.41; 95% confidence interval, 1.29-4.50; P = .006). Follow-up echocardiography for the heart failure with preserved ejection fraction group showed no significant changes in early diastolic mitral annular velocity or left ventricular filling pressure compared with preoperative values.
Conclusions
On the basis of noninvasive assessment using Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, Final Etiology score, a substantial proportion of patients with coronary artery disease who underwent coronary artery bypass grafting had preoperative heart failure with preserved ejection fraction. Preoperative heart failure with preserved ejection fraction was significantly associated with a decrease in the 5-year survival after successful coronary artery bypass grafting.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 18 Jun 2021; epub ahead of print
Lee SH, Choi KH, Song YB, Jeong DS, ... Kim WS, Lee YT
J Thorac Cardiovasc Surg: 18 Jun 2021; epub ahead of print | PMID: 34217536
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Impact:
Abstract

Clinical efficacy of direct or indirect left ventricular unloading during venoarterial extracorporeal membrane oxygenation for primary cardiogenic shock.

Char S, Fried J, Melehy A, Mehta S, ... Kurlansky P, Takeda K
Objective
Left ventricular (LV) distention is a feared complication in patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO). LV unloading can be achieved indirectly with intra-aortic balloon pump (IABP) or directly with an Impella device (Abiomed, Danvers, Mass). We sought to assess the clinical and hemodynamic effects of IABP and Impella devices on patients supported with VA ECMO.
Methods
We conducted a retrospective review of VA ECMO patients at our institution from January 2015 to June 2020. Patients were categorized as either ECMO alone or ECMO with LV unloading. LV unloading was characterized as either ECMO with IABP or ECMO with Impella. We recorded baseline characteristics, survival, complications, and hemodynamic changes associated with device initiation.
Results
During the study, 143 patients received ECMO alone whereas 140 received ECMO with LV unloading (68 ECMO with IABP, 72 ECMO with Impella). ECMO with Impella patients had a higher incidence of bleeding events compared with ECMO alone or ECMO with IABP (52.8% vs 37.1% vs 17.7%; P < .0001). Compared with ECMO alone, ECMO with IABP patients had better survival at 180 days (log rank P = .005) whereas survival in ECMO with Impella patients was not different (log rank P = .66). In a multivariable Cox hazard analysis, age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00-1.03; P = .015), male sex (HR, 0.54; 95% CI, 0.38-0.80; P = .002), baseline lactate (HR, 1.06; 95% CI, 1.02-1.11; P = .004), baseline creatinine (HR, 1.06; 95% CI, 1.00-1.11; P = .032), need for extracorporeal membrane oxygenation-cardiopulmonary resuscitation (HR, 2.09; 95% CI, 1.40-3.39; P = .001), and presence of pre-ECMO IABP (HR, 0.45; 95% CI, 0.25-0.83; P = .010) were associated with reduced mortality. There was no significant difference in hemodynamic changes in the ECMO with IABP versus ECMO with Impella cohorts.
Conclusions
Concomitant support with IABP might help reduce morbidity and improve 180-day survival in patients receiving VA ECMO for cardiogenic shock.

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

J Thorac Cardiovasc Surg: 17 Jun 2021; epub ahead of print
Char S, Fried J, Melehy A, Mehta S, ... Kurlansky P, Takeda K
J Thorac Cardiovasc Surg: 17 Jun 2021; epub ahead of print | PMID: 34243933
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Impact:
Abstract

Diagnostic accuracy of the \"4 A\'s Test\" delirium screening tool for the postoperative cardiac surgery ward.

Chang Y, Ragheb SM, Oravec N, Kent D, ... MacLullich AMJ, Arora RC
Background
Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A\'s Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward.
Methods
This single-center, prospective observational study evaluated the performance of the 4 A\'s Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients\' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A\'s Test in phase 2 of the study.
Results
In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A\'s Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A\'s Test. Compared with the reference rater, the 4 A\'s Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A\'s Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A\'s Test use.
Conclusions
The 4 A\'s Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.

Copyright © 2021 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 31 May 2021; epub ahead of print
Chang Y, Ragheb SM, Oravec N, Kent D, ... MacLullich AMJ, Arora RC
J Thorac Cardiovasc Surg: 31 May 2021; epub ahead of print | PMID: 34243932
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Impact:
Abstract

Influence of facility volume on long-term survival of patients undergoing esophagectomy for esophageal cancer.

Patel DC, Jeffrey Yang CF, He H, Liou DZ, ... Shrager JB, Berry MF
Objective
This study investigated the influence of facility volume on long-term survival in patients with esophageal cancer treated with esophagectomy.
Methods
Patients treated with esophagectomy for cT1 3N0 3M0 adenocarcinoma or squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database between 2006 and 2013 were stratified by annual facility esophagectomy volume dichotomized as more/less than both 6 and 20. Patient characteristics associated with facility volume were evaluated using logistic regression, and the influence of facility volume on survival was evaluated with Kaplan-Meier curves, Cox proportional hazards methods, and propensity matched analysis.
Results
Of 11,739 patients who had esophagectomy at 1018 facilities where annual volume ranged from 1 to 47.6 cases, 4262 (36.3%) were treated at 44 facilities with annual esophagectomy volume > 6 and 1515 (12.9%) were treated at 7 facilities with annual volume > 20. Higher volume was associated with significantly better 5-year survival for both annual volume > 6 (47.6% vs 40.2%; P < .001) and annual volume > 20 (47.2% vs 42.3%; P < .001), which persisted in propensity matched analyses as well as Cox multivariable analysis (hazard ratio, 0.81; 95% confidence interval, 0.74-0.89; P < .001 for facility volume > 6 and hazard ratio, 0.78; 95% confidence interval, 0.65-0.95; P = .01 for facility volume > 20). In Cox multivariable analysis that considered facility volume as a continuous variable, higher volume continued to be associated with better survival (hazard ratio, 0.93 per 5 cases; 95% CI, 0.91-0.96; P < .001).
Conclusions
Esophageal cancer patients treated with esophagectomy at higher volume facilities have significantly better long-term survival than patients treated at lower volume facilities.

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

J Thorac Cardiovasc Surg: 09 Jun 2021; epub ahead of print
Patel DC, Jeffrey Yang CF, He H, Liou DZ, ... Shrager JB, Berry MF
J Thorac Cardiovasc Surg: 09 Jun 2021; epub ahead of print | PMID: 34247867
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Impact:
Abstract

Left ventricle-mitral valve ring size mismatch following ring annuloplasty for nonischemic dilated cardiomyopathy.

Misumi Y, Kainuma S, Toda K, Miyagawa S, ... Sawa Y, Osaka Cardiovascular Surgery Research (OSCAR) Study Group
Background
In patients with ischemic mitral regurgitation (MR) undergoing restrictive mitral annuloplasty (RMA), the ratio of left ventricular (LV) end-systolic dimension (LVESD) to mitral valve (MV) ring size (ie, LV-MV ring mismatch) is associated with postoperative recurrent MR. However, the impact of LV-MV ring mismatch on postoperative recurrent MR, LV function recovery, and long-term survival in patients with nonischemic dilated cardiomyopathy (DCM) remains unknown.
Methods
Sixty-six patients with nonischemic DCM (mean LVESD, 62 mm) underwent RMA (mean ring size, 26 mm) between 2003 and 2014. Recurrent MR was defined as MR grade ≥2+ at a 6-month echocardiographic evaluation.
Results
At the 6-month follow-up, 23 patients (35%) had developed recurrent MR. In univariable logistic regression analysis, larger LVESD (P = .012) and LVESD/ring size ratio (P = .008) were associated with recurrent MR. In multivariable models adjusted for age, sex, baseline LV ejection fraction, and severe MR, only LVESD/ring size ratio (odds ratio, 4.65; 95% confidence interval, 1.04-25.0; P = .048) remained significantly associated with MR recurrence. Receiver operating characteristic curve analysis demonstrated an optimal cutoff value for the LVESD/ring size ratio of 2.42. Patients with an LVESD/ring size ratio >2.42 (n = 30; mismatch) had a lower 5-year cumulative survival rate compared with those with an LVESD/ring size ratio ≤2.42 (n = 36; nonmismatch) (52% vs 71%; P = .045). Postoperatively, LV dimensions were significantly reduced in both groups; however, improvements in LVEF were only modest in the mismatched group (P = .091).
Conclusions
LV-MV ring size mismatch was associated with an increased risk of recurrent MR in our series. This finding may aid the formulation of surgical strategies for patients with nonischemic DCM.

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

J Thorac Cardiovasc Surg: 07 Jun 2021; epub ahead of print
Misumi Y, Kainuma S, Toda K, Miyagawa S, ... Sawa Y, Osaka Cardiovascular Surgery Research (OSCAR) Study Group
J Thorac Cardiovasc Surg: 07 Jun 2021; epub ahead of print | PMID: 34246489
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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

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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Impact:
Abstract

Complete revascularization during coronary artery bypass grafting is associated with reduced major adverse events.

Bianco V, Kilic A, Aranda-Michel E, Serna-Gallegos D, ... Navid F, Sultan I
Objective
Complete revascularization literature is limited by variance in patient cohorts and inconsistent definitions. The objective of the current study was to provide risk-adjusted outcomes for complete revascularization of significant nonmain-branch and main-branch vessel stenoses.
Methods
All patients that underwent first-time isolated coronary artery bypass grafting procedures were included. Kaplan-Meier survival estimates, cumulative incidence function, and Cox regression were used to analyze outcomes.
Results
The total population consisted of 3356 patients that underwent first-time isolated coronary artery bypass grafting. Eight hundred eighty-nine (26.5%) patients had incomplete and 2467 (73.5%) had complete revascularization. For main-branch vessels, 677 (20.2%) patients had incomplete revascularization and 2679 (79.8%) were completely revascularized. Following risk adjustment with inverse probability treatment weighting, all baseline characteristics were balanced (standardized mean difference, ≤ 0.10). On Kaplan-Meier estimates, survival at 1 year (94.6% vs 92.5%) and 5 years (86.5% vs 82.1%) (P = .05) was significantly better for patients who received complete revascularization. Freedom from major adverse cardiac and cerebrovascular events was significantly higher for the complete revascularization cohort at both 1 year (89.2% vs 84.2%) and 5 years (72.5% vs 66.7%) (P < .001). Complete revascularization (hazard ratio, 0.82; 95% confidence interval, 0.70-0.95; P = .01) was independently associated with a significant reduction in major adverse cardiac and cerebrovascular events. Incomplete revascularization of nonmain-branch vessels was not associated with mortality (hazard ratio, 1.14; 95% confidence interval, 0.74-1.8; P = .55) or major adverse cardiac and cerebrovascular events (hazard ratio, 0.90; 95% confidence interval, 0.66-1.24; P = .52).
Conclusions
Complete surgical revascularization of all angiographically stenotic vessels in patients with multivessel coronary artery disease is associated with fewer major adverse events. Incomplete revascularization of nonmain-branch vessels is not associated with survival or major adverse cardiac and cerebrovascular events.

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

J Thorac Cardiovasc Surg: 08 Jun 2021; epub ahead of print
Bianco V, Kilic A, Aranda-Michel E, Serna-Gallegos D, ... Navid F, Sultan I
J Thorac Cardiovasc Surg: 08 Jun 2021; epub ahead of print | PMID: 34272071
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Impact:
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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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

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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Impact:
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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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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Impact:

This program is still in alpha version.