Journal: J Thorac Cardiovasc Surg

Sorted by: date / 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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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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Abstract

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

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

Copyright © 2021. Published by Elsevier Inc.

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

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

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

Published by Elsevier Inc.

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

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

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

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

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

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

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

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

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

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

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

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

J Thorac Cardiovasc Surg: 21 Jun 2021; epub ahead of print
Liu Y, Yu M, Wu Y, Wu F, Feng X, Zhao H
J Thorac Cardiovasc Surg: 21 Jun 2021; epub ahead of print | PMID: 34275621
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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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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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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

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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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

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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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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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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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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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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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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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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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

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

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

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

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

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

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

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

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

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

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

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

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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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

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

Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery.

Bonacchi M, Dokollari A, Parise O, Sani G, ... Bisleri G, Gelsomino S
Objectives
Ministernotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques.
Methods
The data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067).
Results
After propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan-Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087).
Conclusions
Minimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.

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

J Thorac Cardiovasc Surg: 22 Apr 2021; epub ahead of print
Bonacchi M, Dokollari A, Parise O, Sani G, ... Bisleri G, Gelsomino S
J Thorac Cardiovasc Surg: 22 Apr 2021; epub ahead of print | PMID: 33994208
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Impact:
Abstract

Urine metabolites for preoperative prediction of acute kidney injury after coronary artery bypass graft surgery.

Tian M, Liu X, Chen L, Hu S, ... Gao H, Sun W
Objective
Acute kidney injury is a common complication after on-pump coronary artery bypass grafting. Prediction of acute kidney injury remains a challenge. Our study aims to identify a panel of urine metabolites for preoperative warning of acute kidney injury after on-pump coronary artery bypass grafting.
Methods
A total of 159 patients undergoing isolated on-pump coronary artery bypass grafting were enrolled from July 7, 2017, to May 17, 2019. Preoperative urine samples were analyzed with the approach of liquid chromatography-mass spectrometry-based urine metabolomics. The study end point was the episode of acute kidney injury within 48 hours postoperatively. The predictive performance was determined by the area under the curve and calibration curve. The results were validated using bootstrap resampling.
Results
The acute kidney injury (n = 55) and nonacute kidney injury (n = 104) groups showed significant different metabolic profiling. A total of 28 metabolites showed significant differences between the acute kidney injury and nonacute kidney injury groups. A metabolite panel of 5 metabolites (tyrosyl-gamma-glutamate, deoxycholic acid glycine conjugate, 5-acetylamino-6-amino-3-methyluracil, arginyl-arginine, and L-methionine) was discovered to have a good predicting performance (area under the curve, 0.89; 95% confidence interval, 0.82-0.93), which is higher than the clinical factor-based model (area under the curve, 0.63; 95% confidence interval, 0.53-0.72). Internal validation by bootstrap resampling showed an adjusted area under the curve of 0.88, and the calibration curve demonstrated good agreement between prediction and observation in the probability of postoperative acute kidney injury. Decision curve analysis revealed a superior net benefit of the metabolite model over the traditional clinical factor-based model.
Conclusions
We present 5 urine metabolites related to acute kidney injury after coronary artery bypass grafting. This metabolite model may serve as a preoperative warning of acute kidney injury after on-pump coronary artery bypass grafting.

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

J Thorac Cardiovasc Surg: 21 Apr 2021; epub ahead of print
Tian M, Liu X, Chen L, Hu S, ... Gao H, Sun W
J Thorac Cardiovasc Surg: 21 Apr 2021; epub ahead of print | PMID: 33994002
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Impact:
Abstract

External stenting and disease progression in saphenous vein grafts two years after coronary artery bypass grafting: A multicenter randomized trial.

Taggart DP, Gavrilov Y, Krasopoulos G, Rajakaruna C, ... Friedrich I, InVESTigators
Objectives
Little data exist regarding the potential of external stents to mitigate long-term disease progression in saphenous vein grafts. We investigated the effect of external stents on the progression of saphenous vein graft disease.
Methods
A total of 184 patients undergoing isolated coronary artery bypass grafting, using an internal thoracic artery graft and at least 2 additional saphenous vein grafts, were enrolled in 14 European centers. One saphenous vein graft was randomized to an external stent, and 1 nonstented saphenous vein graft served as the control. The primary end point was the saphenous vein graft Fitzgibbon patency scale assessed by angiography, and the secondary end point was saphenous vein graft intimal hyperplasia assessed by intravascular ultrasound in a prespecified subgroup at 2 years.
Results
Angiography was completed in 128 patients and intravascular ultrasound in the entire prespecified cohort (n = 51) at 2 years. Overall patency rates were similar between stented and nonstented saphenous vein grafts (78.3% vs 82.2%, P = .43). However, the Fitzgibbon patency scale was significantly improved in stented versus nonstented saphenous vein grafts, with Fitzgibbon patency scale I, II, and III rates of 66.7% versus 54.9%, 27.8% versus 34.3%, and 5.5% versus 10.8%, respectively (odds ratio, 2.02; P = .03). Fitzgibbon patency scale was inversely related to saphenous vein graft minimal lumen diameter, with Fitzgibbon patency scale I, II, and III saphenous vein grafts having an average minimal lumen diameter of 2.62 mm, 1.98 mm, and 1.32 mm, respectively (P < .05). Externally stented saphenous vein grafts also showed significant reductions in mean intimal hyperplasia area (22.5%; P < .001) and thickness (23.5%; P < .001).
Conclusions
Two years after coronary artery bypass grafting, external stenting improves Fitzgibbon patency scales of saphenous vein grafts and significantly reduces intimal hyperplasia area and thickness. Whether this will eventually lead to improved long-term patency is still unknown.

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

J Thorac Cardiovasc Surg: 20 Apr 2021; epub ahead of print
Taggart DP, Gavrilov Y, Krasopoulos G, Rajakaruna C, ... Friedrich I, InVESTigators
J Thorac Cardiovasc Surg: 20 Apr 2021; epub ahead of print | PMID: 34024615
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Impact:
Abstract

Thoracoscopic ablation delays progression from paroxysmal to persistent atrial fibrillation.

Li X, Li M, Shao Y, Gu W, ... Gu J, Chen M
Objective
The study objective was to determine whether mini-invasive transthoracoscopic atrial fibrillation ablation can delay the progression of atrial fibrillation from paroxysmal to persistent.
Methods
Patients aged 18 to 80 years with paroxysmal nonvalvular atrial fibrillation and a history of stroke or systemic thromboembolism were consecutively enrolled from September 2014 to June 2019. In the treatment group, patients underwent transthoracoscopic atrial fibrillation ablation plus left atrial appendage excision (atrial fibrillation ablation plus left atrial appendage excision group). Patients unwilling to receive surgical intervention were treated with antiarrhythmic drugs and oral anticoagulants and recruited as a control group (atrial fibrillation plus antiarrhythmic drugs group). The primary end point was the progression of atrial fibrillation from paroxysmal to persistent.
Results
This study included 49 patients in the atrial fibrillation plus antiarrhythmic drugs group (29 men) and 77 patients in the atrial fibrillation ablation plus left atrial appendage excision group (48 men). In the atrial fibrillation ablation plus left atrial appendage excision group, after a median follow-up of 951 days (interquartile range, 529-1366 days), 8 patients (10.4%) progressed to persistent atrial fibrillation. In the atrial fibrillation plus antiarrhythmic drugs group, after a median follow-up of 835 days (interquartile range, 548-1214 days), 14 patients (28.6%) progressed to persistent atrial fibrillation. The atrial fibrillation ablation plus left atrial appendage excision group had a significantly lower incidence of atrial fibrillation progression than the atrial fibrillation plus antiarrhythmic drugs group during follow-up (3.9 vs 12.3 per 100 person-years, log-rank 8.6, P = .003).
Conclusions
Patients with paroxysmal nonvalvular atrial fibrillation who chose to undergo transthoracoscopic atrial fibrillation ablation had a lower incidence of progression to persistent atrial fibrillation than patients who chose conservative therapy. This strategy might be especially suitable for patients with paroxysmal nonvalvular atrial fibrillation at high risk of stroke and high risk of bleeding.

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

J Thorac Cardiovasc Surg: 18 Apr 2021; epub ahead of print
Li X, Li M, Shao Y, Gu W, ... Gu J, Chen M
J Thorac Cardiovasc Surg: 18 Apr 2021; epub ahead of print | PMID: 33992460
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Impact:
Abstract

Late results after stand-alone surgical ablation for atrial fibrillation.

MacGregor RM, Bakir NH, Pedamallu H, Sinn LA, ... Melby SJ, Damiano RJ
Objectives
Stand-alone surgical ablation of atrial fibrillation is indicated in patients with refractory atrial fibrillation who have failed medical or catheter-based ablation. Few reports of late outcomes after stand-alone surgical ablation exist using comprehensive follow-up with strict definitions of success. This study examined our late outcomes of the stand-alone Cox-Maze IV procedure.
Methods
Between January 2003 and December 2019, 236 patients underwent a stand-alone Cox-Maze IV for refractory atrial fibrillation. Freedom from atrial tachyarrhythmias was assessed by electrocardiography, Holter, or pacemaker interrogation for up to 10 years, with a mean follow-up of 4.8 ± 3.5 years. Rhythm outcomes were compared in multiple subgroups. Factors associated with recurrence were determined using Fine-Gray regression, allowing for death as the competing risk.
Results
The majority of patients (176/236, 75%) had nonparoxysmal atrial fibrillation. Median duration of preoperative atrial fibrillation was 6.2 years (interquartile range, 3-11). Fifty-nine percent of patients (140/236) failed 1 or more prior catheter-based ablation. Thirteen patients (6%) experienced a major complication. There was no 30-day mortality. Freedom from atrial tachyarrhythmias was 94% (187/199), 89% (81/91), and 77% (24/31) at 1, 5, and 10 years, respectively. There was no difference in freedom from atrial tachyarrhythmias between patients with paroxysmal atrial fibrillation versus nonparoxysmal atrial fibrillation (P > .05) or those undergoing sternotomy versus a minimally invasive approach (P > .05). Increased left atrial size and number of catheter ablations were associated with late atrial fibrillation recurrence. For patients who experienced any atrial tachyarrhythmia recurrence, the median number of recurrences was 1.5 (1.0-3.0).
Conclusions
The stand-alone Cox-Maze IV had excellent late efficacy at maintaining sinus rhythm in patients with symptomatic, refractory atrial fibrillation, with low morbidity and no mortality. The Cox-Maze IV, in contrast to catheter-based ablation, was equally effective in patients with paroxysmal and nonparoxysmal atrial fibrillation.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 16 Apr 2021; epub ahead of print
MacGregor RM, Bakir NH, Pedamallu H, Sinn LA, ... Melby SJ, Damiano RJ
J Thorac Cardiovasc Surg: 16 Apr 2021; epub ahead of print | PMID: 34045056
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Impact:
Abstract

Aortic root anatomy after aortic valve reimplantation.

Irace FG, Chirichilli I, Salica A, D\'Aleo S, ... Garufi L, De Paulis R
Objective
During the last decade, special concerns have been raised about the anatomic relationships among the sinotubular junction, ventricular-aortic junction, and virtual basal ring to improve the results of root reconstruction. The aim of this study is to evaluate the in vivo anatomy of the aortic root after reimplantation with the Valsalva graft and the anatomic relationship between its components.
Methods
We analyzed 10 consecutive patients with tricuspid aortic valves who underwent reimplantation with the Valsalva graft between September and December 2019. Surgical clips were applied as markers at the level of proximal annular knots and at the distal reimplanted commissures on the neo-sinotubular junction. Electrocardiogram-gated computed tomography scan of the aortic root was performed. Coordinates of the markers were exported on a 3-dimensional modeling software, and the distances between the virtual basal ring and the Dacron graft basal landmarks were measured.
Results
The mean heights of Dacron graft basal landmarks from virtual basal ring were right-left commissure 7.1 ± 5.1 mm; right sinus 4.7 ± 4.1 mm; right-noncoronary commissure 2.8 ± 2.2 mm; noncoronary sinus 1.4 ± 1.6 mm; left-noncoronary commissure 2.2 ± 2.3 mm; and left sinus 2.0 ± 0.9 mm. The mean planar distances of basal Dacron graft landmarks from virtual basal ring (thickness) were right-left commissure 5.3 ± 3.1 mm; right sinus 2.8 ± 1.4 mm; right-noncoronary commissure 2.2 ± 1.5 mm; noncoronary sinus 1.5 ± 1.5 mm; left-noncoronary commissure 1.3 ± 1.0 mm; and left sinus 3.4 ± 2.5 mm.
Conclusions
After reimplantation, despite a complete dissection of the root, slight asymmetry of graft proximal seating exists. The inner annuloplasty is on the virtual basal ring, and the proximal edge of the Dacron graft is on the ventricular-aortic junction at a slightly different thickness and height along the annular circumference. At the level of the right sinus and left/right commissure, the Dacron graft is higher than the virtual basal ring and the relative wall thickness is increased. The annular stabilization is unaffected.

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

J Thorac Cardiovasc Surg: 15 Apr 2021; epub ahead of print
Irace FG, Chirichilli I, Salica A, D'Aleo S, ... Garufi L, De Paulis R
J Thorac Cardiovasc Surg: 15 Apr 2021; epub ahead of print | PMID: 33985805
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Impact:
Abstract

Late results of aortic valve repair for isolated severe aortic regurgitation.

Tamer S, Mastrobuoni S, Vancraeynest D, Lemaire G, ... Khoury GE, de Kerchove L
Objectives
The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques.
Methods
The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence.
Results
Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation.
Conclusions
Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve-sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.

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

J Thorac Cardiovasc Surg: 15 Apr 2021; epub ahead of print
Tamer S, Mastrobuoni S, Vancraeynest D, Lemaire G, ... Khoury GE, de Kerchove L
J Thorac Cardiovasc Surg: 15 Apr 2021; epub ahead of print | PMID: 34049711
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Impact:
Abstract

Impact of time from symptom onset to operation on outcome of repair of acute type A aortic dissection with malperfusion.

Nakai C, Izumi S, Haraguchi T, Henmi S, ... Mikami T, Tsukube T
Objectives
We analyzed patients with acute type A aortic dissection complicated by malperfusion syndrome to establish whether the timing of operative treatment and the location of malperfusion are factors in determining outcomes.
Methods
A total of 331 patients with acute type A aortic dissection were treated surgically between August 2003 and May 2019. Eighty-four patients (25%) presented with preoperative malperfusion syndrome. Fifty-eight patients with malperfusion syndrome (69%) were transferred to the operating room within 5 hours of the onset of symptoms (immediate repair); 26 patients (31%) were transferred after 5 hours (later repair). We analyzed the effects of immediate aortic repair on surgical outcomes.
Results
There was no significant difference in the early mortality rates between patients with immediate and later aortic repair, which were 20.0% (n = 11/58) and 26.9% (n = 7/19), respectively (P = .12). Preoperative coronary malperfusion was the only predictor of early mortality. The cumulative 5-year survivals of patients with malperfusion syndrome in the immediate and later repair groups were 76.7% and 45.4%, respectively. A significant difference was noted in the long-term outcomes between the 2 groups (P = .02). On multivariable Cox survival analysis, coronary malperfusion and shock on arrival were associated with increased long-term mortality (P < .01 and P = .04). Conducting surgery within 5 hours of the onset of symptoms was a significant predictor of favorable long-term outcome (P = .03).
Conclusions
Although preoperative coronary malperfusion and shock on arrival worsened the long-term outcomes in patients undergoing aortic repair for acute type A aortic dissection with preoperative malperfusion syndrome, conducting an operation within 5 hours of the onset of symptoms significantly improved their long-term outcomes.

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

J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print
Nakai C, Izumi S, Haraguchi T, Henmi S, ... Mikami T, Tsukube T
J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print | PMID: 33941373
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Impact:
Abstract

Late incidence and recurrence of new-onset atrial fibrillation after isolated surgical aortic valve replacement.

Björn R, Nissinen M, Lehto J, Malmberg M, ... Gunn J, Kiviniemi TO
Objectives
Atrial fibrillation (AF) is a common complication after cardiac surgery. More knowledge is needed about long-term AF recurrence and adverse outcomes related to new-onset AF (NOAF) during the index hospitalization.
Methods
A total of 1073 patients underwent isolated surgical aortic valve replacement at the 4 participating hospitals (2002-2014). After the exclusion of patients with a history of any preoperative AF, the final study population included 529 patients in the bioprosthetic and 253 patients in the mechanical valve prosthesis cohort. Median follow-up time was 5.4 (interquartile range, 3.4-8.2) years in the combined cohort.
Results
Altogether 333 (42.6%) patients had in-hospital NOAF and 250 (32.0%) AF after hospital discharge. In the mechanical cohort, 64 (25.3%) experienced in-hospital NOAF and 74 (29.2%) AF after hospital discharge, whereas in the bioprosthetic cohort, 269 (50.9%) patients had in-hospital NOAF and 176 (33.3%) AF after hospital discharge. Patients with NOAF during the index hospital stay had a multifold risk of AF after hospital discharge in the combined cohort (hazard ratio [HR], 3.68; 95% confidence interval [CI], 2.82-4.81; P < .0001) as well as in both cohorts separately (bioprosthetic: HR, 4.35; 95% CI, 3.05-6.22; P < .001; mechanical: HR, 2.54; 95% CI, 1.59-4.03; P < .001). Patients with an in-hospital NOAF also had a significantly higher adjusted risk of death during the follow-up in the mechanical (HR, 2.05; 95% CI, 1.10-3.82; P = .025) and bioprosthetic (HR, 1.63; 95% CI, 1.17-2.28; P = .004) valve prosthesis cohorts.
Conclusions
NOAF during the index hospitalization is associated with a 2- to 4-fold risk of later AF and 1.6- to 2.0-fold risk of all-cause mortality after mechanical and bioprosthetic surgical aortic valve replacement.

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

J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print
Björn R, Nissinen M, Lehto J, Malmberg M, ... Gunn J, Kiviniemi TO
J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print | PMID: 33934899
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Impact:
Abstract

Allergic response to medical products in patients with alpha-gal syndrome.

Kuravi KV, Sorrells LT, Nellis JR, Rahman F, ... Bianchi JR, Turek JW
Background
Galactose-α-1,3-galactose (alpha-gal) is a carbohydrate that is ubiquitously expressed in all mammals except for primates and humans. Patients can become sensitized to this antigen and develop alpha-gal syndrome (AGS), or a red meat allergy. Symptoms range from generalized gastroenteritis and malaise to anaphylaxis, and in endemic areas, the prevalence can be as high as 20%. Although AGS patients commonly avoid alpha-gal by avoiding meat, patients have also developed symptoms due to animal-derived medical products and devices. With the rise in transcatheter aortic valve replacement, we investigate the immunogenicity of common cardiac materials and valves.
Objective
To assess the in vitro immunoglobulin E response toward common medical products, including cardiac patch materials and bioprosthetic valves in patients with AGS.
Methods
Immunoblot and immunohistochemistry techniques were applied to assess immunoglobulin E reactivity to various mammalian derived tissues and medical products for patients with AGS.
Results
AGS serum showed strong reactivity to all of the commercially available, nonhuman products tested, including various decellularized cardiac patch materials and bioprosthetic aortic valves. AGS serum did not react to tissues prepared using alpha-gal knockout pigs.
Conclusions
Despite commercial decellularization processes, alpha-gal continues to be present in animal-derived medical products, including bioprosthetic valves. Serum from patients with AGS demonstrates a strong affinity for these products in vitro. This may have serious potential implications for sensitized patients undergoing cardiac surgery, including early valve failure and accelerated coronary artery disease.

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

J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print
Kuravi KV, Sorrells LT, Nellis JR, Rahman F, ... Bianchi JR, Turek JW
J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print | PMID: 33933257
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Impact:
Abstract

Preoperative physical frailty assessment among octogenarians undergoing cardiac surgery: Upgrading the \"eyeball\" test.

Lim S, Jacques F, Babaki S, Babaki Y, ... Kalavrouziotis D, Mohammadi S
Objectives
There are many well-described, but as yet unproven, physical ability tools to assess frailty. The objective of this study was to evaluate the effectiveness of 4 preoperative physical tests in predicting mortality, morbidity, and functional outcomes among octogenarians undergoing cardiac surgery.
Methods
Between 2016 and 2019, 200 patients aged 80 years or more undergoing elective cardiac surgery were prospectively recruited. Four physical tests were performed preoperatively: 5-m walk time, timed up-and-go, 5 time sit-to-stand, and handgrip strength tests. The primary end point was a composite of in-hospital mortality, neurologic, and pulmonary complications. Multivariate analysis was performed.
Results
In-hospital mortality was 1.5%. Slow performance on the 5-m walk test (time ≥6.4 seconds) was the only independent predictor of the composite end point among the tests evaluated (odds ratio, 2.70; 95% confidence interval, 1.34-5.45; P = .006). At follow-up, patients with a slow 5-m walk test had a significantly lower midterm survival compared with patients with a normal test result (1-year survival 91.5% vs 98.7%, log-rank P = .03). Mean Physical and Mental Component Scores of the 12-item short form survey were 47.2 ± 8.3 and 53.6 ± 5.9, respectively, which are comparable to those of a general population aged more than 75 years.
Conclusions
The 5-m walk time test is an independent predictor of a composite of in-hospital mortality and major morbidity, as well as midterm survival. This test could be used as a simple adjunctive preoperative tool for octogenarians undergoing cardiac surgery.

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

J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print
Lim S, Jacques F, Babaki S, Babaki Y, ... Kalavrouziotis D, Mohammadi S
J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print | PMID: 33965218
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Impact:
Abstract

Perioperative outcomes of pulmonary resection after neoadjuvant pembrolizumab in patients with non-small cell lung cancer.

Tong BC, Gu L, Wang X, Wigle DA, ... Ready NE, D\'Amico TA
Objectives
Pembrolizumab is a programmed death receptor-1 masking antibody approved for metastatic non-small cell lung cancer. This Phase 2 study (NCT02818920) of neoadjuvant pembrolizumab in non-small cell lung cancer had a primary end point of safety and secondary end points of efficacy and correlative science.
Methods
Patients with untreated clinical stage IB to IIIA non-small cell lung cancer were enrolled. Two cycles of pembrolizumab (200 mg) were administered before surgery. Standard adjuvant chemotherapy and radiation were encouraged but not required. Four cycles of adjuvant pembrolizumab were provided.
Results
Of 35 patients enrolled, 30 received neoadjuvant pembrolizumab and 25 underwent lung resection. Only 1 patient had a delay before surgery attributed to pembrolizumab; this was due to thyroiditis. All patients underwent anatomic resection and mediastinal lymph node dissection; the majority (18/25%, 72%) of patients underwent lobectomy. Of the 25 patients, 23 had an initial minimally invasive approach (92%); 5 of these were converted to thoracotomy (21.7%). R0 resection was achieved in 22 patients (88%), and major pathologic response was observed in 7 of 25 patients (28%). The most common postoperative adverse event was atrial fibrillation, affecting 6 of 25 patients (24%). Median chest tube duration and length of stay were 3 and 4 days, respectively. One patient required readmission to the hospital within 30 days. There was no mortality within 90 days of surgery.
Conclusions
In this study, pembrolizumab was safe and well tolerated in the neoadjuvant setting, and its use was not associated with excess surgical morbidity or mortality. Minimally invasive approaches are feasible in this patient population, but may be more challenging than in cases without neoadjuvant immunotherapy. Pathologic response was higher than typically observed with standard neoadjuvant chemotherapy.

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

J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print
Tong BC, Gu L, Wang X, Wigle DA, ... Ready NE, D'Amico TA
J Thorac Cardiovasc Surg: 08 Apr 2021; epub ahead of print | PMID: 33985811
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Impact:
Abstract

Total anomalous pulmonary venous connection: Influence of heterotaxy and venous obstruction on outcomes.

Spigel ZA, Edmunds EE, Caldarone CA, Hickey EJ, Binsalamah ZM, Heinle JS
Background
Previous studies have demonstrated increased early mortality and pulmonary vein reintervention for patients with total anomalous pulmonary venous connection (TAPVC) and heterotaxy syndrome (HTX+) compared with patients with TAPVC without heterotaxy syndrome (HTX-). We aimed to evaluate the longitudinal risk of pulmonary vein reintervention and mortality in HTX + patients.
Methods
A retrospective review was performed to identify longitudinal interventions in patients with TAPVC seen at a single center from 1995 to 2019. The mean cumulative interventions were described for all patients using the Nelson-Aalen estimator. Survival with TAPVC was described using Kaplan-Meier estimates.
Results
A total of 336 patients were identified with TAPVC, of whom 118 (35%) had heterotaxy syndrome. Functional single ventricles were identified in 106 of these 118 HTX + patients (90%) and in 14 of 218 HTX- patients (6%) (P < .001). Obstructed TAPVC (OBS+) was present in 49 of 118 HTX + patients (42%) and in 87 of 218 HTX- patients (40%) (P = .89). The median duration of follow-up was 6.5 years. Five-year survival was 69% for HTX+/OBS + patients, 72% for HTX+/OBS- patients, 86% for HTX-/OBS + patients, and 95% for HTX-/OBS- patients (P < .0001, log-rank test). The mean number of pulmonary vein interventions at the median follow-up time was greater in the HTX+/OBS + patients compared with HTX+/OBS- patients (mean, 2.0 vs 1.1; P = .030), HTX-/OBS + patients (mean, 1.3; P = .033), and HTX-/OBS- patients (mean, 1.3; P = .029).
Conclusions
Among the 4 cohorts, HTX+ was associated with a higher rate of mortality, and HTX+/OBS+ was associated with a greater number of pulmonary vein interventions. This may be due in part to the high prevalence of single ventricle physiology in the HTX + cohort.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 01 Apr 2021; epub ahead of print
Spigel ZA, Edmunds EE, Caldarone CA, Hickey EJ, Binsalamah ZM, Heinle JS
J Thorac Cardiovasc Surg: 01 Apr 2021; epub ahead of print | PMID: 33966882
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Impact:
Abstract

Atrial fibrillation after cardiac surgery: A systematic review and meta-analysis.

Caldonazo T, Kirov H, Rahouma M, Robinson NB, ... Doenst T, POAF-MA Group
Objective
New-onset postoperative atrial fibrillation (POAF) after cardiac surgery is common, with rates up to 60%. POAF has been associated with early and late stroke, but its association with other cardiovascular outcomes is less known. The objective was to perform a meta-analysis of the studies reporting the association of POAF with perioperative and long-term outcomes in patients with cardiac surgery.
Methods
We performed a systematic review and a meta-analysis of studies that presented outcomes for cardiac surgery on the basis of the presence or absence of POAF. MEDLINE, EMBASE, and the Cochrane Library were assessed; 57 studies (246,340 patients) were selected. Perioperative mortality was the primary outcome. Inverse variance method and random model were performed. Leave-one-out analysis, subgroup analyses, and metaregression were conducted.
Results
POAF was associated with perioperative mortality (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.58-2.33), perioperative stroke (OR, 2.17; 95% CI, 1.90-2.49), perioperative myocardial infarction (OR, 1.28; 95% CI, 1.06-1.54), perioperative acute renal failure (OR, 2.74; 95% CI, 2.42-3.11), hospital (standardized mean difference, 0.80; 95% CI, 0.53-1.07) and intensive care unit stay (standardized mean difference, 0.55; 95% CI, 0.24-0.86), long-term mortality (incidence rate ratio [IRR], 1.54; 95% CI, 1.40-1.69), long-term stroke (IRR, 1.33; 95% CI, 1.21-1.46), and longstanding persistent atrial fibrillation (IRR, 4.73; 95% CI, 3.36-6.66).
Conclusions
The results suggest that POAF after cardiac surgery is associated with an increased occurrence of most short- and long-term cardiovascular adverse events. However, the causality of this association remains to be established.

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

J Thorac Cardiovasc Surg: 31 Mar 2021; epub ahead of print
Caldonazo T, Kirov H, Rahouma M, Robinson NB, ... Doenst T, POAF-MA Group
J Thorac Cardiovasc Surg: 31 Mar 2021; epub ahead of print | PMID: 33952399
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Abstract

Comparative study of Japanese frozen elephant trunk device for open aortic arch repairs.

Ogino H, Okita Y, Uchida N, Kato M, ... Nakai M, J-Open Cardiac Aortic Arch Disease Replacement Surgical Therapy Study Investigators
Objective
We performed a multicenter prospective comparative study to determine the impact of a Japanese frozen elephant trunk device on total arch replacement compared with conventional repair without it.
Methods
Between 2016 and 2019, a total of 684 patients (frozen elephant trunk procedure; n = 369; conventional repair, n = 315) from 41 institutions were enrolled. The 2 procedures were selected according to each center\'s strategy.
Results
The frozen elephant trunk procedure was applied more for aortic dissection, whereas the conventional repairs were predominantly performed for aneurysms. In the former, only hypothermic circulatory arrest time was reduced among the intraoperative parameters. Although there were no differences in the 30-day and in-hospital mortality rates (0.8% and 1.6%, respectively, for the frozen elephant trunk procedure vs 0.3% and 0.6%, respectively, for conventional repair), the neurologic complication rates were significantly higher in stroke (5.7% vs 2.2%; P = .022) and paraplegia (1.6% vs 0%; P = .023). In the propensity score matching analyses using 11 variables, statistical significance disappeared in the differences for mortality and neurologic morbidity (stroke and paraplegia/paraparesis) rates of 194 patients of each group, although they were still higher for the frozen elephant trunk procedure.
Conclusions
The early outcomes of total arch replacement with the frozen elephant trunk procedure were acceptable despite its higher prevalence of emergency or redo surgery, which was comparable to that of the conventional repair. This procedure had higher rates of spinal cord injury than the conventional repair, which is a disadvantage of this approach.

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

J Thorac Cardiovasc Surg: 31 Mar 2021; epub ahead of print
Ogino H, Okita Y, Uchida N, Kato M, ... Nakai M, J-Open Cardiac Aortic Arch Disease Replacement Surgical Therapy Study Investigators
J Thorac Cardiovasc Surg: 31 Mar 2021; epub ahead of print | PMID: 33965229
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Abstract

Coronary artery bypass grafting after acute ST-elevation myocardial infarction.

Elbadawi A, Elzeneini M, Elgendy IY, Megaly M, ... Brilakis ES, Jneid H
Objectives
The study objectives were to describe the trends and outcomes of isolated coronary artery bypass grafting after ST-elevation myocardial infarction using a nationwide database.
Methods
We queried the 2002-2016 National Inpatient Sample database for hospitalized patients with ST-elevation myocardial infarction who underwent isolated coronary artery bypass grafting. We report temporal trends, predictors, and outcomes of coronary artery bypass grafting in the early (2002-2010) and recent (2011-2016) cohorts.
Results
Of 3,347,470 patients hospitalized for ST-elevation myocardial infarction, 7.7% underwent isolated coronary artery bypass grafting. The incidence of isolated coronary artery bypass grafting after ST-elevation myocardial infarction decreased over time (9.2% in 2002 vs 5.5% in 2016, Ptrend < .001), whereas perioperative crude in-hospital mortality did not change (5.1% in 2002 vs 4.2% in 2016, Ptrend = .66), coinciding with an increase in the burden of comorbidities. There was an increase in performing isolated coronary artery bypass grafting on hospitalization day 3 or more, as well as an increase in the use of mechanical support devices and precoronary artery bypass grafting percutaneous coronary intervention. In the early cohort, isolated coronary artery bypass grafting on days 1 and 2 was associated with higher in-hospital mortality. In the recent cohort, coronary artery bypass grafting on day 2 had similar in-hospital mortality compared with day 3 or more and lower rates of acute kidney injury, ischemic stroke, ventricular arrhythmia, and length of hospital stay.
Conclusions
In this nationwide analysis, there has been a decline in the use of isolated coronary artery bypass grafting after ST-elevation myocardial infarction. Isolated coronary artery bypass grafting on day 1 was performed in sicker patients and was associated with higher in-hospital mortality than coronary artery bypass grafting performed on day 3 or more. In the recent cohort, isolated coronary artery bypass grafting on day 2 had similar in-hospital mortality compared with day 3 or more.

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

J Thorac Cardiovasc Surg: 30 Mar 2021; epub ahead of print
Elbadawi A, Elzeneini M, Elgendy IY, Megaly M, ... Brilakis ES, Jneid H
J Thorac Cardiovasc Surg: 30 Mar 2021; epub ahead of print | PMID: 33931231
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Abstract

Application of deep hypothermic circulatory arrest in open left chest aortic aneurysm repair.

Alhussaini M, Falasa MP, Jeng EI, Martin T, ... Neal D, Beaver TM
Objectives
Deep hypothermic circulatory arrest (DHCA) is often required for patients undergoing repair of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm via left thoracotomy when proximal crossclamping is not feasible or when aneurysmal disease extends into the transverse aortic arch. Historical literature suggests higher complications rates due to the technical complexity of this approach; we examined outcomes with this approach at our center.
Methods
Between January 2008 and May 2018, 84 patients with DTAA or Crawford extent I thoracoabdominal aortic aneurysm underwent open repair. DHCA was employed in 46 of 84 (55%) patients, of which 33 (72%) required repair of distal arch and DTAA, and 13 (28%) required repair of the distal arch and extent I thoracoabdominal aortic aneurysm. Patients who underwent DHCA had more chronic dissections than those in the non-DHCA group (70% vs 34%; P ≤ .05).
Results
Major adverse outcomes for the DHCA group versus non-DHCA group were as follows: early mortality 3 out of 46 (7%) versus 4 out of 38 (11%) (P = .70), stroke 3 out of 46 (7%) versus 1 out of 38 (3%) (P = .62), permanent spinal cord deficit 2 out of 46 (4%) versus 3 out of 38 (8%) (P = .65), permanent renal failure necessitating dialysis 1 out of 46 (2%) versus 2 out of 38 (5%) (P = .59). Freedom from major adverse outcomes was 38 out of 46 (83%) versus 31 out of 38 (82%) for DHCA versus non-DHCA (P = 1).
Conclusions
DHCA can be employed via left thoracotomy for combined arch and DTAA or extent I thoracoabdominal aortic aneurysm open repair.

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

J Thorac Cardiovasc Surg: 30 Mar 2021; epub ahead of print
Alhussaini M, Falasa MP, Jeng EI, Martin T, ... Neal D, Beaver TM
J Thorac Cardiovasc Surg: 30 Mar 2021; epub ahead of print | PMID: 33934896
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Abstract

Differences among sexes in presentation and outcomes in acute type A aortic dissection repair.

Norton EL, Kim KM, Fukuhara S, Wu X, ... Deeb GM, Yang B
Objective
Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair.
Methods
From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database.
Results
Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged 80 years or older being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes.
Conclusions
Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.

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

J Thorac Cardiovasc Surg: 28 Mar 2021; epub ahead of print
Norton EL, Kim KM, Fukuhara S, Wu X, ... Deeb GM, Yang B
J Thorac Cardiovasc Surg: 28 Mar 2021; epub ahead of print | PMID: 33902911
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Abstract

Effect of thoracic surgery regionalization on long-term survival after lung cancer resection.

Ely S, Jiang SF, Dominguez DA, Patel AR, Ashiku SK, Velotta JB
Objective
Existing evidence demonstrates some benefit of regionalization on early postoperative outcomes following lung cancer resection, but data regarding the persistence of this effect in long-term mortality are lacking. We investigated whether previously reported improvements in short-term outcomes translated to long-term survival benefit.
Methods
We retrospectively reviewed patients undergoing major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) for cancer within our integrated health care system before (2011-2013; n = 782) and after (2015-2017; n = 845) thoracic surgery regionalization. Overall survival was compared by Kaplan-Meier analysis, and 1- and 3-year mortality was compared by the by χ2 or Fisher exact test. Multivariable Cox regression models evaluated the effect of regionalization on mortality adjusted for relevant factors.
Results
Kaplan-Meier curves showed that overall survival was better among patients undergoing surgery postregionalization (log-rank test, P < .0001). Both 1- and 3-year mortality were decreased after regionalization: to 5.7% from 11.1% (P < .0001) for 1 year and to 17.0% from 25.5% (P = .0002) for 3 years. The multivariable adjusted Cox regression analysis revealed that only regionalization (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.42-0.76), age (HR, 1.03; 95% CI, 1.02-1.04), cancer stage (HR, 1.72, 1.83, and 2.56 for stages II, III, and IV, respectively), and Charlson comorbidity index (HR, 1.80 for 1-2; 2.05 for ≥3) were independent predictors of mortality.
Conclusions
We found that overall mortality as well as 1- and 3-year mortality for lung cancer resection were lower after thoracic surgery regionalization. The association between regionalization and reduced mortality was significant even after adjusting for other related factors in a multivariable Cox analysis. Notably, surgeon volume, facility volume, surgeon specialty, neoadjuvant treatment, and video-assisted thoracoscopic surgery approach did not significantly affect mortality in the adjusted model.

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

J Thorac Cardiovasc Surg: 19 Mar 2021; epub ahead of print
Ely S, Jiang SF, Dominguez DA, Patel AR, Ashiku SK, Velotta JB
J Thorac Cardiovasc Surg: 19 Mar 2021; epub ahead of print | PMID: 33934900
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Abstract

Bioprosthetic versus mechanical mitral valve replacements in patients with rheumatic heart disease.

Chen CY, Chan YH, Wu VC, Liu KS, ... Chu PH, Chen SW
Background
Rheumatic heart disease (RHD) remains a critical problem in developed countries. Few studies have compared the long-term outcomes of bioprosthetic valves and mechanical valves in patients with RHD who have received mitral valve (MV) replacement.
Methods
Patients with RHD who received MV replacement with bioprosthetic or mechanical valves were identified between 2000 and 2013 from Taiwan\'s National Health Insurance Research Database. The primary late outcomes of interest were all-cause mortality and redo MV surgery. Propensity score matching at a 1:1 ratio was performed.
Results
We identified 3638 patients with RHD who underwent MV replacement. Among those patients, 1075 (29.5%) and 2563 (70.5%) chose a bioprosthetic valve and mechanical valve, respectively. After matching, 788 patients were assigned to each group. No significant difference in the risk of in-hospital mortality was observed between groups (P = .920). Higher risks of all-cause mortality (10-year actuarial estimates: 50.6% vs 45.5%; hazard ratio, 1.19; 95% confidence interval, 1.01-1.41; P = .040) and MV reoperation (10-year actuarial estimates: 8.9% vs 0.93%; subdistribution hazard ratio, 4.56; 95% confidence interval, 1.71-12.17; P <.01) were observed in the bioprosthetic valve group. Furthermore, the relative mortality benefit associated with mechanical valves was more apparent in younger patients and the beneficial effect persisted until approximately 65 years of age.
Conclusions
In the patients with RHD who underwent MV replacement, mechanical valves were associated with more favorable long-term outcomes in patients younger than the age of 65 years.

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

J Thorac Cardiovasc Surg: 17 Mar 2021; epub ahead of print
Chen CY, Chan YH, Wu VC, Liu KS, ... Chu PH, Chen SW
J Thorac Cardiovasc Surg: 17 Mar 2021; epub ahead of print | PMID: 33840468
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Abstract

The fate of aortic valve after rheumatic mitral valve surgery.

Kim HR, Kim WK, Kim HJ, Kim JB, ... Chung CH, Lee JW
Objective
Deterioration of the native aortic valve function by a late progression of rheumatic disease is not infrequent in patients who underwent rheumatic mitral valve surgery; however, this phenomenon has not been clearly quantified.
Methods
A total of 1155 consecutive patients (age 52.0 ± 12.9 years; 807 female) who underwent rheumatic mitral valve surgery without concomitant aortic valve surgery from 1997 to 2015 were enrolled. The primary end point was the composite of progression to severe aortic valve dysfunction or a requirement of subsequent aortic valve replacements during follow-up. To determine the risk factors of the primary outcome, we performed the generalized linear mixed model.
Results
The baseline severities of aortic valve were none to trivial in 880 patients (76.2%), mild in 256 patients (22.2%), and moderate in 19 patients (1.6%). The latest 1062 echocardiographic assessments (91.9%; median, 81.2 postoperative months; interquartile range, 37.3-132.1 months) demonstrated 26 cases (0.33%/patient-year) meeting the primary end point during follow-up. Cumulative incidence of the primary end point at 10 years was 0.4% ± 0.3% and 7.4% ± 2.5% depending on the presence of mild or greater aortic valve dysfunction at baseline (P < .01). In multivariable analyses, aortic valve peak pressure gradient (odds ratio, 1.14; 95% confidence interval, 1.10-1.20), aortic regurgitation degree (mild over none: odds ratio, 3.26; 95% confidence interval, 1.15-9.23), and time (odds ratio, 1.30; 95% confidence interval 1.19-1.41) were significantly associated with the occurrence of the primary end point.
Conclusions
Progression of severe aortic valve dysfunction and the need for aortic valve replacement are uncommon in patients undergoing rheumatic mitral valve surgery. However, such events were relatively common among those with mild or greater aortic valve dysfunction at the time of mitral valve surgery.

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

J Thorac Cardiovasc Surg: 17 Mar 2021; epub ahead of print
Kim HR, Kim WK, Kim HJ, Kim JB, ... Chung CH, Lee JW
J Thorac Cardiovasc Surg: 17 Mar 2021; epub ahead of print | PMID: 33867129
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Abstract

Barriers to atrial fibrillation ablation during mitral valve surgery.

Mehaffey JH, Charles EJ, Berens M, Clark MJ, ... Badhwar V, Ailawadi G
Background
Nearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives.
Methods
Adult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included.
Results
Among 66 respondents (66 of 135; 48.9%), the majority reported \"very comfortable/frequently use\" cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors.
Conclusions
Knowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.

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

J Thorac Cardiovasc Surg: 16 Mar 2021; epub ahead of print
Mehaffey JH, Charles EJ, Berens M, Clark MJ, ... Badhwar V, Ailawadi G
J Thorac Cardiovasc Surg: 16 Mar 2021; epub ahead of print | PMID: 33840467
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Abstract

Oxygen delivery-guided perfusion for the prevention of acute kidney injury: A randomized controlled trial.

Mukaida H, Matsushita S, Yamamoto T, Minami Y, ... Asai T, Amano A
Objectives
The reduction of postoperative acute kidney injury in patients undergoing cardiopulmonary bypass surgery using an oxygen delivery-guided perfusion strategy (oxygen delivery strategy) for cardiopulmonary bypass management compared with a fixed flow perfusion (conventional strategy) remains controversial. The purpose of this study was to determine whether a oxygen delivery strategy would reduce the incidence of postoperative acute kidney injury in patients undergoing cardiopulmonary bypass surgery.
Methods
We randomly enrolled 300 patients undergoing cardiopulmonary bypass surgery. Patients were randomly assigned to a oxygen delivery strategy (maintaining a oxygen delivery index value >300 mL/min/m2 through pump flow adjustments during cardiopulmonary bypass) or a conventional strategy (a target pump flow was determined on the basis of the body surface area). The primary end point was the development of acute kidney injury. Secondary end points were the red blood cell transfusion rate and number of red blood cell units, intubation time, postoperative length of stay in the intensive care unit and the hospital, predischarge estimated glomerular filtration rate, and hospital mortality.
Results
Acute kidney injury occurred in 20 patients (14.6%) receiving the oxygen delivery strategy and in 42 patients (30.4%) receiving the conventional strategy (relative risk, 0.48; 95% confidence interval, 0.30-0.77; P = .002). The secondary end points were not significantly different between strategies. In a prespecified subgroup analysis of patients who had nadir hematocrit less than 23% or body surface area less than 1.40 m2, the oxygen delivery strategy seemed to be superior to the conventional strategy and the existence of quantitative interactions was suggested.
Conclusions
An oxygen delivery strategy for cardiopulmonary bypass management was superior to a conventional strategy with respect to preventing the development of acute kidney injury.

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

J Thorac Cardiovasc Surg: 15 Mar 2021; epub ahead of print
Mukaida H, Matsushita S, Yamamoto T, Minami Y, ... Asai T, Amano A
J Thorac Cardiovasc Surg: 15 Mar 2021; epub ahead of print | PMID: 33840474
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Impact:
Abstract

Allocation changes in heart transplantation: What has really changed?

Ganapathi AM, Lampert BC, Mokadam NA, Emani S, ... Tamer R, Whitson BA
Objective
In 2018, the heart allocation system changed status classifications and broadened geographic distribution. We examined this change at a national level based on the immediate pre- and postchange periods.
Methods
Using the Scientific Registry of Transplant Recipients database, we identified all adult primary, isolated heart transplants from October 18, 2017, to October 17, 2019. Two time periods were compared: (1) October 18, 2017, to October 17, 2018 (pre); and (2) October 18, 2018, to October 17, 2019 (post). Comparisons were made between groups, and a multivariable logistic regression model was created to identify factors associated with pretransplant temporary mechanical circulatory support. Volume analysis at the regional, state, and center level was also conducted as the primary focus.
Results
A total of 5381 independent heart transplants were identified within the time frame. On unadjusted analysis, there was a significant increase in temporary mechanical circulatory support (pre, 11.1%; post, 36.2%, P < .01) and decrease in waitlist days (pre, 93 days; post, 41 days; P < .01). Distance traveled (nautical miles) (pre, 83; post, 225; P < .01) and ischemic time (hours) (pre, 3.0; post, 3.4; P < .01) were significantly increased. On multivariable analysis, the postallocation time period was independently associated with temporary MCS (odds ratio, 4.463; 95% confidence interval, 3.844-5.183; P < .001). Transplant volumes did not significantly change after the allocation change at a regional, state, and center level.
Conclusions
Since the planned alteration to the allocation system, there have been changes in the use of temporary mechanical circulatory support as well as distance and ischemic time associated with transplant, but no significant volume changes were observed. Continued observation of outcomes and volume under the new allocation system will be necessary in the upcoming years.

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

J Thorac Cardiovasc Surg: 15 Mar 2021; epub ahead of print
Ganapathi AM, Lampert BC, Mokadam NA, Emani S, ... Tamer R, Whitson BA
J Thorac Cardiovasc Surg: 15 Mar 2021; epub ahead of print | PMID: 33875259
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Impact:
Abstract

The use of blood and blood products in aortic surgery is associated with adverse outcomes.

Sultan I, Bianco V, Aranda-Michel E, Kilic A, ... Wang Y, Gleason TG
Objective
To report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products.
Methods
All patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival.
Results
A total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001).
Conclusions
In patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.

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

J Thorac Cardiovasc Surg: 14 Mar 2021; epub ahead of print
Sultan I, Bianco V, Aranda-Michel E, Kilic A, ... Wang Y, Gleason TG
J Thorac Cardiovasc Surg: 14 Mar 2021; epub ahead of print | PMID: 33838909
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Impact:
Abstract

Clinical impact of the heart team on the outcomes of surgical aortic valve replacement among octogenarians.

Porterie J, Kalavrouziotis D, Dumont E, Paradis JM, ... Rodés-Cabau J, Mohammadi S
Objectives
The effectiveness of a multidisciplinary heart team in the management of patients with severe symptomatic aortic stenosis is unknown. This study evaluated the impact of a heart team on the outcomes of surgical aortic valve replacement in octogenarians.
Methods
Between May 2007 and January 2016, 528 patients aged 80 years or more were referred to our institutional heart team for a transcatheter aortic valve replacement. Among these, 101 were redirected to surgical aortic valve replacement (heart team group). These patients were compared with a surgical aortic valve replacement cohort (n = 506) without prior heart team screening (non-heart team group), taken from the same time period. Propensity score matching with bootstrap analysis was performed; 76 heart team patients were matched to 76 non-heart team patients. Early and late outcomes including survival and readmission for cardiovascular causes were compared.
Results
Matched subgroups were largely comparable; congestive heart failure and echocardiographic pulmonary hypertension were more prevalent in the heart team group. In-hospital mortality was significantly lower in the matched heart team group (0% vs 6.0%, bootstrap mean difference 6.0%, 95% confidence interval, 2.2-9.8). The risk of stroke, low cardiac output state, reexploration for bleeding, pneumonia, and prolonged ventilation was also significantly lower in the heart team group. There was no significant between-group difference regarding late survival (hazard ratio, 0.86, 95% confidence interval, 0.55-1.33, P = .49) or readmission for cardiovascular reasons (hazard ratio, 0.70, 95% confidence interval, 0.41-1.20, P = .19).
Conclusions
Preoperative multidisciplinary assessment of octogenarians by a heart team was associated with lower in-hospital mortality and adverse events after surgical aortic valve replacement.

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

J Thorac Cardiovasc Surg: 10 Mar 2021; epub ahead of print
Porterie J, Kalavrouziotis D, Dumont E, Paradis JM, ... Rodés-Cabau J, Mohammadi S
J Thorac Cardiovasc Surg: 10 Mar 2021; epub ahead of print | PMID: 33840473
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Impact:
Abstract

Ross procedure or complex aortic valve repair using pericardium in children: A real dilemma.

Danial P, Neily A, Pontailler M, Gaudin R, ... Vouhe P, Raisky O
Objective
Difficult to repair aortic valve lesions, requiring the use of a valve substitute, remain controversial in the face of the Ross procedure, despite undeniable technical advances. This study was undertaken to compare midterm outcomes of children treated using the Ross procedure or aortic valvuloplasty for complex aortic valve lesions.
Methods
Between January 2006 and December 2017, 126 patients aged younger than 18 years were treated for complex aortic stenosis and/or aortic insufficiency and were included in this retrospective study. Only aortic valve lesions requiring repair with an autologous or heterologous pericardial patch were considered complex lesions. Propensity score framework analyses were used to compare outcomes of the Ross and aortic valvuloplasty groups while controlling for confounders.
Results
Among the 126 patients with complex aortic valve lesions, propensity score matching selected 34 unique pairs of patients with similar characteristics. Survival (aortic valvuloplasty, 94.1%; Ross, 91%; P = .89), freedom from overall reintervention (aortic valvuloplasty, 50.1%; Ross, 69%; P = .32), and freedom from infective endocarditis at 8 years (aortic valvuloplasty, 100%; Ross, 85.9%; P = .21) were similar. However, freedom from reintervention in the left ventricular outflow tract at 8 years was lower after aortic valvuloplasty than after the Ross procedure (50.1% vs 100%, respectively; P = .001).
Conclusions
Aortic valvuloplasty and the Ross procedure yielded similar 8-year outcomes regarding death, reoperation, and infective endocarditis although aortic valvuloplasty tended to be associated with fewer cases of infective endocarditis. Aortic valvuloplasty using a pericardial patch can be chosen as a first-line strategy for treating complex aortic valve lesions and might offer the possibility of a later Ross procedure.

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

J Thorac Cardiovasc Surg: 09 Mar 2021; epub ahead of print
Danial P, Neily A, Pontailler M, Gaudin R, ... Vouhe P, Raisky O
J Thorac Cardiovasc Surg: 09 Mar 2021; epub ahead of print | PMID: 33820635
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Impact:
Abstract

Comparison of C-C motif chemokine ligand 14 with other biomarkers for adverse kidney events after cardiac surgery.

Massoth C, Küllmar M, Enders D, Kellum JA, ... Zarbock A, Progressive AKI Group
Objective
Outcomes after acute kidney injury are affected by both the severity and the duration of the insult. Patients with persistent acute kidney injury have higher major adverse kidney events, including 90-day mortality, renal replacement therapy, and persistent kidney dysfunction. Methods to identify these patients are urgently needed to improve outcomes. The purpose of this study was to evaluate whether biomarkers, including C-C motif chemokine ligand 14, were able to predict persistent acute kidney injury and major adverse kidney events after cardiac surgery.
Methods
This study was a single-center, prospective, observational study. Patients who developed moderate or severe acute kidney injury (Kidney Disease Improving Global Outcomes 2 or 3) within 72 hours after cardiac surgery were enrolled with a primary end point of persistent severe acute kidney injury (Kidney Disease Improving Global Outcomes 3) lasting 72 hours or more.
Results
A total of 100 patients were available for the primary analysis, and 37 met the primary end point. C-C motif chemokine ligand 14 was the most predictive biomarker for the primary end point with an area under the curve of 0.930 (95% confidence interval, 0.881-0.979). The area under the curve of C-C motif chemokine ligand 14 was significantly higher than the area under the curve for the other biomarkers analyzed. C-C motif chemokine ligand 14 was significantly higher in end point positive patients at enrollment (4.47 ng/mL [2.35-11.5] vs 0.67 ng/mL [0.38-1.07]; P = .001). Sensitivity and specificity were 78% and 95% at a cutoff value of 2.21 ng/mL, respectively. C-C motif chemokine ligand 14 was also highly accurate for predicting renal replacement therapy within 7 days (area under the curve, 0.915; 95% confidence interval, 0.858-0.972; P < .001).
Conclusions
Elevated C-C motif chemokine ligand 14 levels predict persistent acute kidney injury in cardiac surgery patients with moderate or severe acute kidney injury. This new biomarker may help stratify patients destined to receive renal replacement therapy and identify patients who may benefit from novel therapeutic approaches to acute kidney injury.

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

J Thorac Cardiovasc Surg: 09 Mar 2021; epub ahead of print
Massoth C, Küllmar M, Enders D, Kellum JA, ... Zarbock A, Progressive AKI Group
J Thorac Cardiovasc Surg: 09 Mar 2021; epub ahead of print | PMID: 33832791
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Abstract

Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service.

Levy RM, Luketich JD, Brynien D, Mpamaugo C, ... Pennathur A, University of Pittsburgh/UPMC Zenker\'s Diverticulum Study Group
Objective
Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service.
Methods
We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention.
Results
A total of 151 patients (median age, 78 years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2 days (range, 0-18 days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16 months; P < .001). During further follow-up (median, 52 months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n = 5) or redo transoral stapling (n = 3).
Conclusions
Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 09 Mar 2021; epub ahead of print
Levy RM, Luketich JD, Brynien D, Mpamaugo C, ... Pennathur A, University of Pittsburgh/UPMC Zenker's Diverticulum Study Group
J Thorac Cardiovasc Surg: 09 Mar 2021; epub ahead of print | PMID: 34148637
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Abstract

Hospital variability in modifiable factors driving coronary artery bypass charges.

Salenger R, Etchill EW, Fonner CE, Alejo D, ... Ad N, Maryland Cardiac Surgery Quality Initiative
Objective
Coronary artery bypass grafting is associated with significant interhospital variability in charges. Drivers of hospital charge variability remain elusive. We identified modifiable factors associated with statewide interhospital variability in hospital charges for coronary artery bypass grafting.
Methods
Charge data were used as a surrogate for cost. Society of Thoracic Surgeons data from Maryland institutions and charge data from the Maryland Health Care Commission were linked to characterize interhospital charge variability for coronary artery bypass grafting. Multivariable linear regression was used to identify perioperative factors independently related to coronary artery bypass grafting charges. Of the factors independently associated with charges, we analyzed which factors varied between hospitals.
Results
A total of 10,337 patients underwent isolated coronary artery bypass grafting at 9 Maryland hospitals from 2012 to 2016, of whom 7532 patients were available for analyses. Mean normalized charges for isolated coronary artery bypass grafting varied significantly among hospitals, ranging from $30,000 to $57,000 (P < .001). Longer preoperative length of stay, operating room time, and major postoperative morbidity including stroke, renal failure, prolonged ventilation, reoperation, and deep sternal wound infection were associated with greater hospital charges. Incidence of major postoperative events, except stroke and deep sternal wound infection, was variable between hospitals. In a univariate linear regression model, patient risk profile only accounted for approximately 10% of statistical variance in charges.
Conclusions
There is significant charge variability for coronary artery bypass grafting among hospitals within the same state. By targeting variation in preoperative length of stay, operating room time, postoperative renal failure, prolonged ventilation, and reoperation, cardiac surgery programs can realize cost savings while improving quality of care for this resource-intense patient population.

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

J Thorac Cardiovasc Surg: 08 Mar 2021; epub ahead of print
Salenger R, Etchill EW, Fonner CE, Alejo D, ... Ad N, Maryland Cardiac Surgery Quality Initiative
J Thorac Cardiovasc Surg: 08 Mar 2021; epub ahead of print | PMID: 33846006
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Abstract

Renal perfusion with histidine-tryptophan-ketoglutarate compared with Ringer\'s solution in patients undergoing thoracoabdominal aortic open repair.

Kahlberg A, Tshomba Y, Baccellieri D, Bertoglio L, ... Chiesa R, CURITIBA Investigators
Objective
The objective of this study was to compare the efficacy of renal perfusion with Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany) versus enriched Ringer\'s solution for renal protection in patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair.
Methods
Ninety consecutive patients scheduled for elective open TAAA repair were enrolled between 2015 and 2017 in a single-center, phase IV, prospective, parallel, randomized, double-blind trial (the CUstodiol versus RInger: whaT Is the Best Agent [CURITIBA] trial), and randomized to renal arteries perfusion with 4°C Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany; n = 45) or 4°C lactated Ringer\'s solution (n = 45). The incidence of acute kidney injury (AKI) in patients undergoing TAAA open surgery using Custodiol renal perfusion versus an enriched Ringer\'s solution was the primary end point.
Results
Ninety patients completed the study (45 patients in each group). The incidence of postoperative AKI was significantly lower in the Custodiol group (48.9% vs 75.6%; P = .02). In the multivariable model, only the use of Custodiol solution resulted as protective from the occurrence of any AKI (odds ratio, 0.230; 95% confidence interval, 0.086-0.614; P = .003), whereas TAAA type II extent was associated with the development of severe AKI (odds ratio, 4.277; 95% confidence interval, 1.239-14.762; P = .02). At 1-year follow-up, serum creatinine was not significantly different from the preoperative values in both groups.
Conclusions
The use of Custodiol during open TAAA repair was safe and resulted in significantly lower rates of postoperative AKI compared with Ringer\'s solution. These findings support safety and efficacy of Custodiol in this specific setting, which is currently off-label.

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

J Thorac Cardiovasc Surg: 03 Mar 2021; epub ahead of print
Kahlberg A, Tshomba Y, Baccellieri D, Bertoglio L, ... Chiesa R, CURITIBA Investigators
J Thorac Cardiovasc Surg: 03 Mar 2021; epub ahead of print | PMID: 33820636
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Abstract

Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes.

Plowman EK, Anderson A, York JD, DiBiase L, ... Martin T, Jeng EI
Objectives
The study objectives were to determine the prevalence of swallowing impairment in adults after cardiac surgery and examine associated risk factors and health-related outcomes.
Methods
A prospective single-center study was conducted in postoperative adult cardiac surgery patients with no history of dysphagia. A standardized fiberoptic endoscopic evaluation of swallowing was performed within 72 hours of extubation. Blinded raters completed validated outcomes of swallowing safety and efficiency. Demographic, surgical, and postoperative health-related outcomes were collected. Univariate and multivariable regression analyses were performed with odds ratios (OR) and 95% confidence intervals (CIs).
Results
In 182 patients examined, imaging confirmed inefficient swallowing (residue) in 52% of patients and unsafe swallowing in 94% (65% penetrators, 29% aspirators). Silent aspiration was observed in 53% of aspirators, and 32% did not clear aspirate material. Independent risk factors for aspiration included New York Heart Association III and IV (OR, 2.9; CI, 1.2-7.0); reoperation (OR, 2.0; CI, 0.7-5.5); transesophageal echocardiogram images greater than 110 (OR, 2.6; CI, 1.1-6.3); intubation greater than 27 hours (OR, 2.1; CI, 0.8-5.3); and endotracheal tube size 8.0 or greater (OR, 3.1; CI, 1.1-8.6). Patients with 3 or 4 identified risk factors had a 16.4 (CI, 3.2-148.4) and 22.4 (CI, 3.7-244.7) increased odds of aspiration, respectively. Compared with nonaspirators, aspirators waited an additional 85 hours to resume oral intake, incurred $49,372 increased costs, and experienced a 43% longer hospital stay (P < .05). Aspiration was associated with pneumonia (OR, 2.6; CI, 1.1-6.5), reintubation (OR, 5.7; CI, 2.1-14.0), and death (OR, 2.8; CI, 1.2-9.0).
Conclusions
Tracheal aspiration was prevalent, covert, and associated with increased morbidity and mortality.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 02 Mar 2021; epub ahead of print
Plowman EK, Anderson A, York JD, DiBiase L, ... Martin T, Jeng EI
J Thorac Cardiovasc Surg: 02 Mar 2021; epub ahead of print | PMID: 33814177
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Abstract

Predictors of survival following surgical resection of limited-stage small cell lung cancer.

Zhou N, Bott M, Park BJ, Vallières E, ... Sepesi B, Small Cell Lung Cancer Working Group
Background
Adjuvant chemotherapy, postoperative radiation (PORT), and prophylactic cranial irradiation (PCI) have been individually examined in limited-stage small cell lung cancer (SCLC). There is a paucity of data on the effectiveness of each adjuvant treatment modality when used in combination after surgical resection of SCLC.
Methods
Data were collected from 5 cancer centers on all patients with limited-stage SCLC who underwent surgical resection between 1986 and 2019. Univariate and multivariable models were conducted to identify predictors of long-term outcomes, focusing on freedom from recurrence and survival benefit of adjuvant chemotherapy, PORT, and PCI.
Results
A total of 164 patients were analyzed. Multivariable Cox regression analysis did not identify any adjuvant therapies to significantly influence recurrence in this cohort. Specifically, PORT was not associated with a significant influence on locoregional recurrence and PCI was not significantly associated with intracranial outcomes. Adjuvant chemotherapy improved survival in all stage I through III disease (hazard ratio, 0.49; 95% confidence interval, 0.29-0.81; P = .005) and even in pathologically node negative patients (hazard ratio, 0.49; 95% confidence interval, 0.27-0.91; P = .024). Although PCI was found to improve survival in univariate analysis, it was not significant in a multivariable model. PORT was not found to affect survival on either univariate or multivariable analysis.
Conclusions
This is among the largest multi-institutional studies on surgically resected limited-stage SCLC. Our results highlight survival benefit of adjuvant chemotherapy, but did not identify a statistically significant influence from mediastinal PORT or PCI in our cohort. Larger prospective studies are needed to determine the benefit of PORT or PCI in a surgically resected limited-stage SCLC population.

Copyright © 2020. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:760-771.e2
Zhou N, Bott M, Park BJ, Vallières E, ... Sepesi B, Small Cell Lung Cancer Working Group
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:760-771.e2 | PMID: 33349449
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Abstract

Asymptomatic degenerative mitral regurgitation repair: Validating guidelines for early intervention.

Desai A, Thomas JD, Bonow RO, Kruse J, ... Cox JL, McCarthy PM
Introduction
Mitral repair for asymptomatic (New York Heart Association [NYHA] class I) degenerative mitral regurgitation (MR) is supported by the guidelines, but is not performed often. We sought to determine outcomes for asymptomatic patients when compared with those with symptoms.
Methods
Between 2004 and 2018, 1027 patients underwent mitral replacement (22) or repair with or without other cardiac surgery (1005), the latter being grouped by NYHA class: I (n = 470; 47%), II (n = 408; 40%), or III/IV (n = 127; 13%). Statistical analyses included propensity score matching and weighting, and multistate models.
Results
The proportion of patients designated as NYHA class I undergoing surgery increased steadily during this period (P < .001). Overall, 30-day mortality was 0.4%, and zero for patients designated NYHA class I. Unadjusted 10-year survival was significantly greater in patients designated NYHA class I compared with II and III/IV (P < .001). Freedom from reoperation at 10 years was 99.8% overall, and 100% for patients designated NYHA class I. In patients designated as NYHA class I, predischarge and 10-year moderate MR were 0.7% and 20.1%, whereas more than moderate was zero and 0.6%. Preoperative ejection fraction less than 60% was associated with late mortality (P = .025). After covariate-adjustments, freedom from MR and tricuspid regurgitation were not statistically significantly different by NYHA class. However, overall survival was significantly worse in patients with NYHA class III/IV, compared with class II.
Conclusions
Mitral repair in asymptomatic patients is safe and durable. Careful monitoring until class II symptoms is appropriate. However, repair before ejection fraction decreases below 60% is important for late overall survival.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:981-994.e5
Desai A, Thomas JD, Bonow RO, Kruse J, ... Cox JL, McCarthy PM
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:981-994.e5 | PMID: 33419544
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Abstract

Tracheal surgery for airway anomalies associated with increased mortality in pediatric patients undergoing heart surgery: Society of Thoracic Surgeons Database analysis.

Riggs KW, Zafar F, Jacobs ML, Jacobs JP, ... Bryant R, Tweddell JS
Objectives
Airway anomalies are common in children with cardiac disease but with an unquantified impact on outcomes. We sought to define the association between airway anomalies and tracheal surgery with cardiac surgery outcomes using the Society of Thoracic Surgery Congenital Heart Surgery Database.
Methods
Index cardiac operations in children aged less than 18 years (January 2010 to September 2018) were identified from the Society of Thoracic Surgery Congenital Heart Surgery Database. Patients were divided on the basis of reported diagnosis of an airway anomaly and subdivided on the basis of tracheal lesion and tracheal surgery. Multivariable analysis evaluated associations between airway disease and outcomes controlling for covariates from the Society of Thoracic Surgery Congenital Heart Surgery Database Mortality Risk Model.
Results
Of 198,674 index cardiovascular operations, 6861 (3.4%) were performed in patients with airway anomalies, including 428 patients (0.2%) who also underwent tracheal operations during the same hospitalization. Patients with airway anomalies underwent more complex cardiac operations (45% vs 36% Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality category ≥3 procedures) and had a higher prevalence of preoperative risk factors (73% vs 39%; both P < .001). In multivariable analysis, patients with airway anomalies had increased odds of major morbidity and tracheostomy (P < .001). Operative mortality was also increased in patients with airway anomalies, except those with malacia. Tracheal surgery within the same hospitalization increased the odds of operative mortality (adjusted odds ratio, 3.9; P < .0001), major morbidity (adjusted odds ratio, 3.7; P < .0001), and tracheostomy (adjusted odds ratio, 16.7; P < .0001).
Conclusions
Patients undergoing cardiac surgery and tracheal surgery are at significantly higher risk of morbidity and mortality than patients receiving cardiac surgery alone. Most of those with unoperated airway anomalies have higher morbidity and mortality, which makes it an important preoperative consideration.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1112-1121.e7
Riggs KW, Zafar F, Jacobs ML, Jacobs JP, ... Bryant R, Tweddell JS
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1112-1121.e7 | PMID: 33419543
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Abstract

Factors associated with unplanned reinterventions and their relation to early mortality after pediatric cardiac surgery.

Dorobantu DM, Ridout D, Brown KL, Rodrigues W, ... Tsang VT, Stoica SC
Objective
Unplanned reintervention (uRE) is used as an indicator of patient morbidity and quality of care in pediatric cardiac surgery. We investigated associated factors and early mortality after uREs.
Methods
Morbidity data were prospectively collected in 5 UK centers between 2015 and 2017; uRE included surgical cardiac, interventional transcatheter cardiac, permanent pacemaker, and diaphragm plication procedures. Mortality (30-day and 6-month) in uRE/no-uRE patients was reported before and after matching. Predicted 30-day mortality was calculated using the Partial Risk Adjustment in Surgery score.
Results
A total of 3090 procedures (2861 patients) were included (median age, 228 days). There were 146 uREs, resulting in an uRE rate of 4.7%. Partial Risk Adjustment in Surgery score, 30-day mortality and 6-month mortality in uRE and no-uRE groups were 2.4% versus 1.3%, 8.9% versus 1%, and 17.1% versus 2.4%, respectively. After matching, mortality at 6 months remained higher in uRE compared with no-uRE (12.2% vs 1.4%; P = .02; 74 pairs). In the uRE group, 21 out of 25 deaths at 6 months occurred when at least 1 additional postoperative complication was present. In multivariable analysis, neonatal age (P = .002), low weight (P = .009), univentricular heart (P < .001), and arterial shunt (P < .001) were associated with increased risk of uRE, but Partial Risk Adjustment in Surgery score was not (only in univariable analysis).
Conclusions
uREs are a relatively frequent complication after pediatric cardiac surgery and are associated with some patient characteristics, but not the Partial Risk Adjustment in Surgery risk score. Early mortality was higher after uRE, independent of preoperative factors, but linked to other postoperative complications.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1155-1166.e9
Dorobantu DM, Ridout D, Brown KL, Rodrigues W, ... Tsang VT, Stoica SC
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1155-1166.e9 | PMID: 33419533
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Abstract

Lessons from reoperations for mitral stenosis after mitral valve repair.

El-Eshmawi A, Sun E, Boateng P, Pandis D, ... Anyanwu A, Adams DH
Background
The durability of mitral valve repair (MVr) is usually defined by the absence of recurrent significant mitral regurgitation. Postrepair mitral stenosis (MS) is a less frequent and less studied mode of failure of MVr. We analyzed our experience in patients who underwent reoperation for postrepair MS to characterize mechanisms resulting in MS and to summarize reoperative surgical strategies and mid-term outcomes.
Methods
Using a prospective database, we retrospectively analyzed data on 35 consecutive patients who underwent reoperation for symptomatic moderate to severe MS between January 1, 2011, and February 1, 2020.
Results
The mean patient age was 61.4 ± 11.4 years, and 69% were female. The median annuloplasty ring size used at the initial repair was 28 mm (interquartile range, 26-30 mm). Additional repair techniques at the initial operation included leaflet resection in 12 patients (34%) and commissuroplasty or edge-to-edge repair in 6 patients (18%). At reoperation, the most common mechanism of MS was pannus ingrowth in 20 patients (57%), leaflet calcification in 12 (34%), commissural fusion in 5 (14%), and tunnel effect (functional MS) in 3 (9%). Twenty-two patients (63%) underwent valve replacement, and 13 (37%) underwent valve re-repair. In patients who underwent re-repair, annuloplasty revision was performed in all patients, with 6 patients (46%) converted from complete ring to band, 4 (11%) converted from ring to pericardial annuloplasty, 2 (6%) converted to no annuloplasty, and 1 (8%) with annuloplasty ring upsizing. There were no in-hospital or 1-year mortalities. Survival at the 5-year follow-up was 93.9%.
Conclusions
MS causing late failure of MVr is frequently associated with smaller ring sizes and inflammatory or calcific changes in the valve. Highly selected patients may be good candidates for mitral valve re-repair.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:937-946
El-Eshmawi A, Sun E, Boateng P, Pandis D, ... Anyanwu A, Adams DH
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:937-946 | PMID: 33431213
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Abstract

Relation between functional coronary artery stenosis and graft occlusion after coronary artery bypass grafting.

Hwang HY, Paeng JC, Kang J, Jang MJ, Kim KB
Objectives
This study was conducted to evaluate graft patency rates during the 5 years after coronary artery bypass grafting according to the functional significance of the coronary artery stenosis, as determined by myocardial single-photon-emission computed tomography.
Methods
Two hundred ninety-five patients who underwent coronary artery bypass grafting using Y-composite grafts based on the in situ left internal thoracic artery, and in whom preoperative stress/rest myocardial single-photon-emission computed tomography and 1-year angiographies were available were enrolled. Seven hundred sixty-nine and 262 distal anastomoses were constructed to ischemic and nonischemic areas, respectively. One-year and 5-year angiographic occlusion rates were evaluated in all and 80.3% of study patients, respectively. Factors associated with graft occlusion were evaluated using generalized linear mixed-effects models.
Results
Overall 1- and 5-year graft occlusion rates were 4.3% (44 of 1031 distal anastomoses) and 5.5% (45 out of 820), respectively. The occlusion rates of grafts bypassed to vessels with functionally significant and insignificant stenosis were 2.7% (21 out of 769) and 8.8% (23 out of 262) at 1 year and were 4.0% (25 out of 618) and 9.9% (20 out of 202) at 5 years, respectively. Graft occlusion during the 5 years after coronary artery bypass grafting was associated with the functional significance of coronary artery stenosis (odds ratio, 0.50; 95% confidence interval, 0.28-0.92). The odds ratio of the graft occlusion according to functional ischemia was lower and significant in grafts to arteries with intermediate stenosis (stenosis ≥70% but <90%; odds ratio, 0.34; 95% confidence interval, 0.13-0.93) whereas it was higher and insignificant in grafts to arteries with severe stenosis (≥90% stenosis; odds ratio, 0.76; 95% confidence interval, 0.33-1.72).
Conclusions
Graft occlusion during the 5 years after coronary artery bypass grafting was associated with the functional significance of coronary artery stenosis, particularly when the stenosis degree was not severe.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1010-1018.e1
Hwang HY, Paeng JC, Kang J, Jang MJ, Kim KB
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1010-1018.e1 | PMID: 33431208
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Impact:
Abstract

Gender representation among leadership at national and regional cardiothoracic surgery organizational annual meetings.

Shemanski KA, Ding L, Kim AW, Blackmon SH, ... Starnes VA, David EA
Background
Increased attention has been dedicated to gender inequity at scientific meetings. This study evaluated the gender distribution of session leaders at cardiothoracic surgery national and regional meetings.
Methods
This is a descriptive study of the gender of peer-selected session leaders at 4 cardiothoracic surgery organizations\' annual meetings from 2015 to 2019. Session leaders included moderators, panelists, and invited discussants. Data from publicly available programs were used to generate a list of session leaders and organization leaders. The primary outcome measure was the proportion of female session leaders at annual meetings. Descriptive analyses were performed, including the Cochran-Armitage trend test for linear trends of proportions.
Results
A total of 679 sessions over 20 meetings were examined. Of the 3662 session leaders, 480 (13.1%) were women. The proportion of total female session leaders trended positively over time from 9.6% (56 of 581) in 2015 to 15.9% (169 of 1060) in 2019 (P = .001). Among specialty topic sessions, female session leaders were distributed as follows: adult cardiac, 6.9% (81 of 1172); congenital cardiac, 10.8% (47 of 437); and thoracic, 23.2% (155 of 668). The proportion of female session leaders trended significantly only for thoracic sessions (20.6% [21 of 102] in 2015 to 29.2% [58 of 199] in 2019; P = .02). More than one-half of the sessions (57.4%; 390 of 679) featured all-male session leadership.
Conclusions
Women remain underrepresented in leadership roles at cardiothoracic surgery organizational meetings. This may deter female applicants and has implications for female surgeons\' career trajectories; therefore, attention must be given to the potential for unconscious bias in leadership in cardiothoracic surgery.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:733-744
Shemanski KA, Ding L, Kim AW, Blackmon SH, ... Starnes VA, David EA
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:733-744 | PMID: 33431207
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Impact:
Abstract

Trends in the traditional cardiothoracic surgery resident operative experience for cardiac cases: An analysis of Accreditation Council for Graduate Medical Education case logs.

Shah AM, Siddiqui E, Holmes SD, Okoh A, ... Kaushal S, Sambol J
Objective
To determine whether the changing cardiac landscape has affected traditional cardiothoracic surgery (CTS) resident case volume, particularly cardiac case volume.
Methods
The Accreditation Council for Graduate Medical Education (ACGME) case logs for traditional CTS residents from 2016 to 2019 were reviewed. Using linear and nonlinear regression, trends in the annual volume and proportion of CTS operations were examined.
Results
Overall, the average number of total and category-specific CTS resident cases have increased from 2016 to 2019. However, in general, the proportion of thoracic surgery cases has been increasing, and the proportion of cardiac surgery cases has been decreasing. In particular, the proportion of coronary atherosclerosis (-0.2546 per 100 cases/year; P < .001) and valvular heart disease (-0.319 per 100 cases/year; P < .001) procedures demonstrated the greatest downward trends. The average operative experience for residents has increased (28.8 cases/resident/year; P < .001), but cardiac track residents (22.24 cases/resident/year; P < .001) have had a smaller increase than thoracic track residents (35.04 cases/resident/year; P < .001). Nevertheless, cardiac track residents experienced an increase in their average proportion of cardiac cases (0.176 per 100 cases/year; P < .001) compared with average (-0.263 per 100 cases/year; P < .001) and thoracic track (-0.978 per 100 cases/year; P < .001) CTS residents, indicating specialization of the tracks.
Conclusions
The overall CTS resident operative experience has increased over the last several years, with cardiac cases increasing more slowly than thoracic cases. The analysis reveals that cardiac operative volume has been asymmetrically allocated to cardiac track residents, indicating a greater specialization of the tracks. Annual evaluation of CTS resident case volume will provide essential insight into the field.

Copyright © 2020 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1064-1075.e3
Shah AM, Siddiqui E, Holmes SD, Okoh A, ... Kaushal S, Sambol J
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1064-1075.e3 | PMID: 33436298
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Impact:
Abstract

First in human experience with an epicardial beating heart device for secondary mitral regurgitation.

Thourani VH, George I, Rucinskas K, Kalinauskas G, ... Smith R, Mack MJ
Objective
We describe a novel, off-pump, epicardial implant that is intended to reshape both the mitral valve annulus and the left ventricle (LV) in those with secondary mitral regurgitation (MR).
Methods
Five patients underwent an epicardial implant with the Mitral Touch device (Mitre Medical Corp, Morgan Hill, Calif), during concomitant off-pump coronary artery bypass for secondary MR. The median age was 71.2 years; 4 patients had severe MR and 1 moderate. Patients were followed for 1 year with transthoracic echocardiography and computed tomography. Safety, cardiac remodeling, and MR were assessed by an independent core laboratory.
Results
One patient died within 30 days from nondevice-related organ failure and the remaining 4 survived through 1-year follow-up. Implant technical success was 100% and took an average of 52 minutes. Paired computed tomography showed mean left ventricular end-systolic volume remodeling at 1 and 12 months of -35% and -31%, respectively. They averaged left atrial end-systolic volume remodeling of -12% and -15% at 1 and 12 months. Right ventricular end-systolic volume changes of -19% and -8% and right atrial end-systolic volume remodeling of -5% and 1%, at the 1- and 12-month time points were noted. Regurgitant volume by transthoracic echocardiography decreased by 46% and 44% and the ejection fraction from 34.6% to 32.1% and 39.5%, at 1 and 12 months, respectively. There were no device-related complications reported to 1 year.
Conclusions
The Epicardial Mitral Touch System for Mitral Regurgitation (ENRAPT-MR) study demonstrates a first-in-man, off-pump, epicardial repair of secondary MR. Procedural safety and geometric correction of the mitral valve apparatus and LV was achieved. Further studies in the United States are underway.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:949-958.e4
Thourani VH, George I, Rucinskas K, Kalinauskas G, ... Smith R, Mack MJ
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:949-958.e4 | PMID: 33436291
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Impact:
Abstract

Outcomes of treatment pathways in 240 patients with congenitally corrected transposition of great arteries.

Barrios PA, Zia A, Pettersson G, Najm HK, ... Karamlou T, Members of the ccTGA Working Group
Objective
Congenitally corrected transposition of the great arteries (ccTGA) encompasses a diverse morphologic cohort, for which multiple treatment pathways exist. Understanding surgical outcomes among various pathways and their determinants are challenged by limited sample size and follow-up, and heterogeneity. We sought to investigate these questions with a large cohort of ccTGA patients presenting at different ages and representing the full therapeutic spectrum.
Methods
Retrospective review of 240 patients diagnosed with ccTGA from Cleveland Clinic coupled with prospective cross-sectional follow-up. Forty-six patients whose definitive procedure was completed elsewhere were excluded. Time-related survival was described among treatment pathways using actuarial, time-varying covariate, and competing risks analyses. Temporal trends in longitudinal valve and ventricular function were assessed using nonlinear mixed-effects models.
Results
Median follow-up was 10 years. Seventy-nine patients with ccTGA underwent anatomic repair, 45 physiologic repair, 24 Fontan palliation, and 6 primary transplant. Forty patients managed expectantly had excellent long-term survival when considered from time of presentation, but benefited from failures captured following transition to physiologic repair or transplant. Morphologic right ventricular dysfunction after physiologic repair increased from 68% to 85% after 5 years, whereas morphologic left ventricular function was stable in anatomic repair, especially with early surgery. Transplant-free survival at 15 years for anatomic and physiologic repair was 80% and 71%, respectively.
Conclusions
Early anatomic repair may be preferable to physiologic repair for select ccTGA patients. Late attrition after physiologic repair represents failure of expectant management and progressive tricuspid valve and morphologic right ventricular dysfunction compared with anatomic repair, where morphologic left ventricular function is relatively preserved.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1080-1093.e4
Barrios PA, Zia A, Pettersson G, Najm HK, ... Karamlou T, Members of the ccTGA Working Group
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1080-1093.e4 | PMID: 33436290
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Abstract

Surgery for laryngotracheal stenosis: Improved results.

Maurizi G, Vanni C, Rendina EA, Ciccone AM, ... Venuta F, D\'Andrilli A
Objective
Laryngotracheal resection is still considered a challenging operation and few high-volume institutions have reported large series of patients in this setting. During the 5 years, novel surgical techniques as well as new trends in the intra- and postoperative management have been proposed. We present results of our increased experience with laryngotracheal resection for benign stenosis.
Methods
Between 1991 and May 2019, 228 consecutive patients underwent laryngotracheal resection for subglottic stenosis. One hundred eighty-three (80.3%) were postintubation, and 45 (19.7%) were idiopathic. Most of them (58.7%) underwent surgery during the past 5 years. At the time of surgery, 139 patients (61%) had received tracheostomy, laser, or laser plus stenting. The upper limit of the stenosis ranged between actual involvement of the vocal cords to 1.5 cm from the glottis.
Results
There was no perioperative mortality. Two hundred twenty-two patients underwent resection and anastomosis according to the Pearson technique; 6 patients with involvement of thyroid cartilage underwent resection and reconstruction with the laryngofissure technique. Airway resection length ranged between 1.5 and 8 cm (mean, 3.8 ± 0.8 cm) and it was >4.5 cm in 19 patients. Airway complication rate was 7.8%. Overall success of airway complication treatment was 83.3%. Definitive success was achieved in 98.7% of patients. Patients presenting with idiopathic stenosis or postcoma patients showed no increased failure rate.
Conclusions
Laryngotracheal resection for benign subglottic stenosis is safe and effective, and provides a very high rate of success. Careful intra- and postoperative management is crucial for a successful outcome.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:845-852
Maurizi G, Vanni C, Rendina EA, Ciccone AM, ... Venuta F, D'Andrilli A
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:845-852 | PMID: 33451851
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Abstract

Looking beyond the eyeball test: A novel vitality index to predict recovery after esophagectomy.

Tang A, Ahmad U, Raja S, Rappaport J, ... Blackstone EH, Murthy SC
Objectives
To (1) measure 4 physiologic metrics before esophagectomy, (2) use these in an index to predict composite postoperative outcome after esophagectomy, and (3) compare predictive accuracy of this index to that of the Fried Frailty Index and Modified Frailty Index.
Methods
Grip strength (kilograms), 30-second chair sit-stands (number), 6-minute walk distance (meters), and normalized psoas muscle area (cm2/m) were measured for 77 consenting patients from January 1, 2018, to April 1, 2019. Imbalanced random forest classification estimated probability of a composite postoperative outcome, which included mortality, respiratory complications, anastomotic leak, delirium, length of stay ≥14 days, discharge to nursing facility, and readmission. G-mean error was used to compare predictive accuracy among indexes.
Results
Median grip strength was 38 kg (25th-75th percentiles, 31-44), number of sit-stands 11 (10-14), psoas muscle area to height ratio 6.9 cm2/m (6.0-8.2), and 6-minute walk distance 407 m (368-451). There was generally weak correlation between these metrics, with the highest between 30-second sit-stands and 6-minute walk distance (r = 0.57). Age, degree of patient-reported exhaustion, and the 4 objective metrics comprised the Esophageal Vitality Index, which had a lower G-mean error of 32% (31-33) than the Fried Frailty Index, 37% (37-38), and the Modified Frailty Index, 48% (47-48).
Conclusions
The Esophageal Vitality Index, an objective, simple assessment consisting of grip strength, 30-second chair sit-stands, 6-minute walk, and psoas muscle area to height ratio outperformed commonly used frailty indexes in predicting postesophagectomy mortality and morbidity. The index provides a robust picture of patients\' fitness for surgery beyond the qualitative \"eyeball\" test.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:822-832.e6
Tang A, Ahmad U, Raja S, Rappaport J, ... Blackstone EH, Murthy SC
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:822-832.e6 | PMID: 33451846
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Abstract

Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion?

Norton EL, Wu X, Kim KM, Fukuhara S, ... Deeb GM, Yang B
Objective
The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion.
Methods
From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143).
Results
The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30).
Conclusions
Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:873-884.e2
Norton EL, Wu X, Kim KM, Fukuhara S, ... Deeb GM, Yang B
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:873-884.e2 | PMID: 33451835
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Abstract

Operative risks of the Ross procedure.

Stelzer P, Mejia J, Varghese R
Background
The risk of the Ross procedure continues to be debated. We sought to determine the immediate outcomes of the Ross procedure in a large consecutive cohort that included patients undergoing reoperative cardiac surgery and/or concomitant cardiac procedures.
Methods
Between March 1987 and September 2019, 702 patients underwent a full root Ross procedure. There were 530 male patients and 172 female patients, with a mean age of 41.6 years. One hundred and one patients had at least one previous sternotomy; 323 patients had concomitant procedures. Patients were stratified into 2 groups: simple and complex. Simple Ross patients were those who had no previous sternotomy and had only minor concomitant procedures performed at the time of their Ross, such as aortoplasty or closure of patent foramen ovale. The complex Ross group included patients with at least one previous sternotomy and/or additional procedures that we deemed complex, such as ascending aortic replacement and mitral valve repair. Complexity and group outcomes were evaluated in consecutive terciles of time.
Results
There were 7 (1%) operative deaths. Morbidity affected 46 other patients (6.6%). The simple Ross group comprised 419 patients (59.7%), with mortality in 3 (0.7%) and morbidity in 20 (4.8%). The complex Ross comprised 283 patients (40.3%), with mortality in 4 (1.4%) and morbidity in 26 (9.2%). Simple Ross cases decreased in volume over time, with complex cases increasing from 34% to 48%.
Conclusions
Excellent results can be achieved with the Ross procedure despite broader indications that include patients with previous sternotomy and with the need for concomitant procedures.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:905-915.e3
Stelzer P, Mejia J, Varghese R
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:905-915.e3 | PMID: 33451826
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Abstract

Midterm outcomes of the Potts shunt for pediatric pulmonary hypertension, with comparison to lung transplant.

Lancaster TS, Shahanavaz S, Balzer DT, Sweet SC, Grady RM, Eghtesady P
Objective
For children with severe pulmonary hypertension, addition of Potts shunt to a comprehensive palliation strategy might improve the outcomes afforded by medications and delay lung transplantation.
Methods
A prospective analysis was conducted of all children undergoing Potts shunt (first performed in 2013) or bilateral lung transplant for pulmonary hypertension from 1995 to present.
Results
A total of 23 children underwent Potts shunt (20 surgical, 3 transcatheter), and 31 children underwent lung transplant. All children with Potts shunt had suprasystemic right ventricle pressures despite maximal medical treatment. In the majority of patients, the Potts shunt was performed through a left thoracotomy approach (90%, 18/20), by direct anastomosis (65%, 13/20), and without the use of extracorporeal support (65%, 13/20). Perioperative outcomes after Potts shunt were superior to lung transplant including mechanical ventilation time (1.3 vs 10.2 days, P = .019), median hospital length of stay (9.8 vs 34 days, P = .012), and overall complication rate (35% [7/20] vs 81% [25/31], P = .003). Risk factors for operative mortality after Potts shunt (20%, 4/20; compared with 6%, 2/31 for lung transplant, P = .195) included preoperative extracorporeal membrane oxygenation and significant right ventricle dysfunction. In midterm follow-up (median 1.8, maximum 6.1 years), patients with Potts shunt had durable equalization of right ventricle/left ventricle pressures and improved functional status. There was no significant survival difference in patients with Potts shunt and patients with lung transplant (P = .258).
Conclusions
Potts shunt is an effective palliation for children with suprasystemic pulmonary hypertension that may become part of a strategy to maximize longevity and functional status for these challenging patients.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1139-1148
Lancaster TS, Shahanavaz S, Balzer DT, Sweet SC, Grady RM, Eghtesady P
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1139-1148 | PMID: 33454101
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Abstract

Pathologic concordance of resected metastatic nonseminomatous germ cell tumors in the chest.

Donahoe LL, Nason GJ, Bedard PL, Hansen AR, ... Hamilton RJ, de Perrot M
Objective
Men with metastatic nonseminomatous germ cell tumors (NSGCTs) often present with residual chest tumors after chemotherapy. We examined the pathologic concordance of intrathoracic disease and outcomes based on the worst pathology of disease resected at first thoracic surgery.
Methods
A retrospective analysis was performed of consecutive patients undergoing thoracic resection for metastatic NSGCT in our institution between 2005 and 2018.
Results
Eighty-nine patients (all men) were included. The median age was 29 years (interquartile range [IQR], 23-35 years). Primary sites were testis (n = 84; 94.4%) and retroperitoneum (n = 5; 5.6%). Eighty-seven patients received chemotherapy before undergoing surgery. Nineteen patients (21.3%; group 1) had malignancy resected at first surgery (OR1), and the other 70 patients had benign disease at OR1 (78.7%; group 2). Concordant pathology between lungs was 85.2% in group 1 and 91% in group 2, and between lung and mediastinum was 50% in group 1 and 72.7% in group 2. Despite no teratoma at OR1, 3 patients (15.8%) in group 2 had resection of teratoma (n = 2) or malignancy (n = 1) at future surgery. After a mean follow-up of 65.5 months (IQR, 23.1-89.2 months) for group 1 and 47.7 months (IQR, 13.0-75.1 months) for group 2, overall survival was significantly worse for group 1 (68.4% vs 92.9%; P = .03).
Conclusions
The wide range of pathology resected in patients with intrathoracic NSGCT metastases requires careful decision making regarding treatment. Pathologic concordance between lungs is better than that between lung and mediastinum in patients with intrathoracic NSGCT metastases. Aggressive surgical management should be considered for all residual disease due to the low concordance between sites and the potential for excellent long-term survival even in patients with chemotherapy-refractory disease.

Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:856-868.e1
Donahoe LL, Nason GJ, Bedard PL, Hansen AR, ... Hamilton RJ, de Perrot M
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:856-868.e1 | PMID: 33478834
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Abstract

Proximal aortic repair in dialysis patients: A national database analysis.

Ogami T, Zimmermann E, Zhu RC, Zhao Y, ... Patel VI, Takayama H
Objectives
Dialysis is a well-established risk factor for morbidity and mortality after cardiovascular procedures. However, little is known regarding the outcomes of proximal aortic surgery in this high-risk cohort.
Methods
Perioperative (in-hospital or 30-day mortality) and 10-year outcomes were analyzed for all the patients who underwent open proximal aortic repair with the diagnosis of nonruptured thoracic aortic aneurysm (aneurysm, n = 325) or type A aortic dissection (dissection, n = 461) from 1987 to 2015 using the US Renal Data System database.
Results
In patients with aneurysm, perioperative mortality was 12.6%. The 10-year mortality was 81% ± 3%. Age 65 years or more (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 to 1.78; P = .03), chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.01-2.82; P = .047), and Black race (HR, 1.46; 95% CI, 1.09-1.97; P = .01) were independently associated with worse 10-year mortality. In patients with dissection, perioperative mortality was 24.3% and 10-year mortality was 87.9% ± 2.2%. Age 65 years or more (HR, 1.49; 95% CI, 1.19-1.86; P < .001), congestive heart failure (HR, 1.39; 95% CI, 1.11-2.57; P = .004), and diabetes mellitus as the cause of dialysis (HR, 1.75; 95% CI, 1.2-2.57; P = .004) were independently associated with worse 10-year mortality. Black race (HR, 0.74; 95% CI, 0.6-0.92; P = .008) was associated with a better outcome.
Conclusions
We described challenging perioperative and 10-year outcomes for dialysis patients undergoing proximal aortic repair. The present study suggests the need for careful patient selection in the elective repair of proximal aortic aneurysm for dialysis-dependent patients, whereas it affirms the feasibility of emergency surgery for acute type A aortic dissections.

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

J Thorac Cardiovasc Surg: 26 Feb 2021; epub ahead of print
Ogami T, Zimmermann E, Zhu RC, Zhao Y, ... Patel VI, Takayama H
J Thorac Cardiovasc Surg: 26 Feb 2021; epub ahead of print | PMID: 33812684
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Abstract

Elucidating the mechanisms underlying left ventricular function recovery in patients with ischemic heart failure undergoing surgical remodeling: A 3-dimensional ultrasound analysis.

Castelvecchio S, Frigelli M, Sturla F, Milani V, ... Menicanti L, Votta E
Objective
The study objective was to elucidate the mechanisms of left ventricle functional recovery in terms of endocardial contractility and synchronicity after surgical ventricular reconstruction.
Methods
Real-time 3-dimensional transthoracic echocardiography was performed on 20 patients with anterior left ventricle remodeling and ischemic heart failure before surgical ventricular reconstruction and at 6-month follow-up, and on 15 healthy controls matched by age and body surface area. Real-time 3-dimensional transthoracic echocardiography datasets were analyzed through TomTec software (4D LV-Analysis; TomTec Imaging Systems GmbH, Unterschleissheim, Germany): Left ventricle volumes, ejection fraction, and global longitudinal strain were computed; the time-dependent endocardial surface yielded by 3-dimensional speckle-tracking echocardiography was postprocessed through in-house software to quantify local systolic minimum principal strain as a measure of fiber shortening and mechanical dispersion as a measure of fiber synchronicity.
Results
Compared with controls, patients with heart failure before surgical ventricular reconstruction showed lower ejection fraction (P < .0001) and significantly impaired mechanical dispersion (P < .0001) and minimum principal strain (P < .0001); the latter worsened progressively from left ventricle base to apex. After surgical ventricular reconstruction, global longitudinal strain improved from -6.7% to -11.3% (P < .0001); mechanical dispersion decreased in every left ventricle region (P ≤ .017) and mostly in the basal region, where computed mechanical dispersion values were comparable to physiologic values (P ≥ .046); minimum principal strain improved mostly in the basal region, changing from -16.6% to -22.3% (P = .0027).
Conclusions
At 6-month follow-up, surgical ventricular reconstruction was associated with significant recovery in global left ventricle function, improved mechanical dispersion indicating a more synchronous left ventricle contraction, and improved left ventricle fiber shortening mostly in the basal region, suggesting the major role of the remote myocardium in enhancing left ventricle functional recovery.

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

J Thorac Cardiovasc Surg: 25 Feb 2021; epub ahead of print
Castelvecchio S, Frigelli M, Sturla F, Milani V, ... Menicanti L, Votta E
J Thorac Cardiovasc Surg: 25 Feb 2021; epub ahead of print | PMID: 33781593
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Abstract

Long-term outcomes of aortic root operations in the United States among Medicare beneficiaries.

Yerokun BA, Vallabhajosyula P, Vekstein AM, Grau-Sepulveda MV, ... Bavaria JE, Hughes GC
Objective
The best method of aortic root repair in older patients remains unknown given a lack of comparative effectiveness of long-term outcomes data. The objective of this study was to compare long-term outcomes of different surgical approaches for aortic root repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services-linked data.
Methods
A retrospective cohort study was performed by querying the Society of Thoracic Surgeons Adult Cardiac Surgery Database for patients aged 65 years or more who underwent elective aortic root repair with or without aortic valve replacement. Primary long-term end points were mortality, any stroke, and aortic valve reintervention. Short-term outcomes and long-term survival were compared among each root repair strategy. Additional risk factors for mortality after aortic root repair were assessed with a multivariable Cox proportional hazards model.
Results
A total of 4173 patients aged 65 years or more underwent elective aortic root repair. Patients were stratified by operative strategy: mechanical Bentall, stented bioprosthetic Bentall, stentless bioprosthetic Bentall, or valve-sparing root replacement. Mean follow-up was 5.0 (±4.6) years. Relative to mechanical Bentall, stented bioprosthetic Bentall (adjusted hazard ratio, 0.80; confidence interval, 0.66-0.97) and stentless bioprosthetic Bentall (adjusted hazard ratio, 0.70; confidence interval, 0.59-0.84) were associated with better long-term survival. In addition, stentless bioprosthetic Bentall (adjusted hazard ratio, 0.64; confidence interval, 0.47-0.80) and valve-sparing root replacement (adjusted hazard ratio, 0.51; confidence interval, 0.29-0.90) were associated with lower long-term risk of stroke. Aortic valve reintervention risk was 2-fold higher after valve-sparing root replacement compared with other operative strategies.
Conclusions
In the Medicare population, there was poorer late survival and greater late stroke risk for patients undergoing mechanical Bentall and a higher rate of reintervention for valve-sparing root replacement. Bioprosthetic Bentall may be the procedure of choice in older patients undergoing aortic root repair, particularly in the era of transcatheter aortic valve replacement.

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

J Thorac Cardiovasc Surg: 24 Feb 2021; epub ahead of print
Yerokun BA, Vallabhajosyula P, Vekstein AM, Grau-Sepulveda MV, ... Bavaria JE, Hughes GC
J Thorac Cardiovasc Surg: 24 Feb 2021; epub ahead of print | PMID: 33814173
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Abstract

Mitral valve repair for isolated posterior mitral valve leaflet prolapse: The effect of respect and resect techniques on left ventricular function.

van Wijngaarden AL, Tomšič A, Mertens BJA, Fortuni F, ... Marsan NA, Palmen M
Objective
Posterior mitral valve leaflet prolapse repair can be performed by leaflet resection or chordal replacement techniques. The impact of these techniques on left ventricular function remains a topic of debate, considering the presumed better preservation of mitral-ventricular continuity when leaflet resection is avoided. We explored the effect of different posterior mitral valve leaflet repair techniques on postoperative left ventricular function.
Methods
In total, 125 patients were included and divided into 2 groups: leaflet resection (n = 82) and isolated chordal replacement (n = 43). Standard and advanced echocardiographic assessments were performed preoperatively, directly postoperatively, and at late follow-up. In addition, left ventricular global longitudinal strain was measured and corrected for left ventricular end-diastolic volume to adjust for the significant changes in left ventricular volumes.
Results
At baseline, no significant intergroup difference in left ventricular function was observed measured with the corrected left ventricular global longitudinal strain (resect: 1.76% ± 0.58%/10 mL vs respect: 1.70% ± 0.57%/10 mL, P = .560). Postoperatively, corrected left ventricular global longitudinal strain worsened in both groups but improved significantly during late follow-up, returning to preoperative values (resect: 1.39% ± 0.49% to 1.71% ± 0.56%/10 mL, P < .001 and respect: 1.30% ± 0.45% to 1.70% ± 0.54%/10 mL, P < .001). Mixed model analysis showed no significant effect on the corrected left ventricular global longitudinal strain when comparing the 2 different surgical repair techniques over time (P = .943).
Conclusions
Our study showed that both leaflet resection and chordal replacement repair techniques are effective at preserving postoperative left ventricular function in patients with posterior mitral valve leaflet prolapse and significant regurgitation.

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

J Thorac Cardiovasc Surg: 22 Feb 2021; epub ahead of print
van Wijngaarden AL, Tomšič A, Mertens BJA, Fortuni F, ... Marsan NA, Palmen M
J Thorac Cardiovasc Surg: 22 Feb 2021; epub ahead of print | PMID: 33744010
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Impact:
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