Alison F. Ward

Minithoracotomy for mitral valve repair improves inpatient and postdischarge economic savings

OBJECTIVE Small series of thoracotomy for mitral valve repair have demonstrated clinical benefit. This multi-institutional administrative database analysis compares outcomes of thoracotomy and sternotomy approaches for mitral repair. METHODS The Premier database was queried from 2007 to 2011 for mitral repair hospitalizations. Premier contains billing, cost, and coding data from more than 600 US hospitals, totaling 25 million discharges. Thoracotomy and sternotomy approaches were identified through expert rules; robotics were excluded. Propensity matching on baseline characteristics was performed. Regression analysis of surgical approach on outcomes and costs was modeled. RESULTS Expert rule analysis positively identified thoracotomy in 847 and sternotomy in 566. Propensity matching created 2 groups of 367. Mortalities were similar (thoracotomy 1.1% vs sternotomy 1.9%). Sepsis and other infections were significantly lower with thoracotomy (1.1% vs 4.4%). After adjustment for hospital differences, thoracotomy carried a 17.2% lower hospitalization cost (-

Outcomes of peripheral perfusion with balloon aortic clamping for totally endoscopic robotic mitral valve repair

8289) with a 2-day stay reduction. Readmission rates were significantly lower with thoracotomy (26.2% vs 35.7% at 30 days and 31.6% vs 44.1% at 90 days). Thoracotomy was more common in southern and northeastern hospitals (63% vs 37% and 64% vs 36%, respectively), teaching hospitals (64% vs 36%) and larger hospitals (>600 beds, 78% vs 22%). CONCLUSIONS Relative to sternotomy, thoracotomy for mitral repairs provides similar mortality, less morbidity, fewer infections, shorter stay, and significant cost savings during primary admission. The markedly lower readmission rates for thoracotomy will translate into additional institutional cost savings when a penalty on hospitals begins under the Affordable Care Acts Hospital Readmissions Reduction Program.

Measurement of mitral leaflet and annular geometry and stress after repair of posterior leaflet prolapse: Virtual repair using a patient specific finite element simulation

OBJECTIVE Although the technique of totally endoscopic robotic mitral valve repair (TERMR) has been well described, few reports have examined the results of peripheral perfusion with balloon clamping. We analyzed the outcomes of TERMR performed using this strategy. METHODS A total of 108 consecutive patients underwent TERMR by a 2-surgeon team. The preoperative evaluation included chest computed tomography and abdominal and pelvis computed tomography. Additional procedures included appendage exclusion in 96, patent foramen ovale closure in 29, cryoablation in 16, tricuspid valve repair in 2, and septal myectomy in 2. The mean patient age was 59 years (range, 21-86). Central venous drainage was obtained with a long cannula. Arterial return was achieved with femoral cannulation, when possible. An endoballoon catheter was placed through the femoral artery. Transesophageal echocardiography was used to position all catheters. RESULTS Femoral artery perfusion was possible in 103 of 108 patients (95.3%). The subclavian artery was used in 5 patients (4.6%) with contraindications to retrograde perfusion. An endoballoon clamp was placed by way of the femoral artery. In 105 of 108 patients (97.2%), endoaortic occlusion was successfully used; the mean crossclamp time was 87.4 minutes. The coronary sinus cardioplegia catheter was placed successfully in 81 of the 108 patients (75%). Postoperatively, no or mild inotropic support was needed in 94 (87%) and moderate support in 14 (13.0%). Of the 108 patients, 55 (50.9%) were extubated in the operating room. No hospital mortality, aortic injury, vascular complications, or wound infections occurred. Complications included 2 strokes (no residual deficit) (1.8%) and atrial fibrillation in 18 (16.7%). The median hospital stay was 4 days. Eighty patients (74.1%) were discharged by postoperative day 5. CONCLUSIONS A preoperative image-guided perfusion strategy and aortic balloon clamping permit routine TERMR with excellent myocardial preservation and minimal complications.

Right anterior thoracotomy aortic valve replacement is associated with less cost than sternotomy-based approaches: a multi-institution analysis of 'real world' data.

BACKGROUND Recurrent mitral regurgitation after mitral valve (MV) repair for degenerative disease occurs at a rate of 2.6% per year and reoperation rate progressively reaches 20% at 19.5 years. We believe that MV repair durability is related to initial postoperative leaflet and annular geometry with subsequent leaflet remodeling due to stress. We tested the hypothesis that MV leaflet and annular stress is increased after MV repair. METHODS Magnetic resonance imaging was performed before and intraoperative three-dimensional (3D) transesophageal echocardiography was performed before and after repair of posterior leaflet prolapse in a single patient. The repair consisted of triangular resection and annuloplasty band placement. Images of the heart were manually co-registered. The left ventricle and MV were contoured, surfaced, and a 3D finite element (FE) model was created. Elements of the posterior leaflet region were removed to model leaflet resection and virtual sutures were used to repair the leaflet defect and attach the annuloplasty ring. RESULTS The principal findings of the current study are the following: (1) FE simulation of MV repair is able to accurately predict changes in MV geometry including changes in annular dimensions and leaflet coaptation; (2) average posterior leaflet stress is increased; and (3) average anterior leaflet and annular stress are reduced after triangular resection and mitral annuloplasty. CONCLUSIONS We successfully conducted virtual mitral valve prolapse repair using FE modeling methods. Future studies will examine the effects of leaflet resection type as well as annuloplasty ring size and shape.

Blood conservation strategies can be applied safely to high-risk complex aortic surgery.

Abstract Background: Large institutional analyses demonstrating outcomes of right anterior mini-thoracotomy (RAT) for isolated aortic valve replacement (isoAVR) do not exist. In this study, a group of cardiac surgeons who routinely perform minimally invasive isoAVR analyzed a cross-section of US hospital records in order to analyze outcomes of RAT as compared to sternotomy. Methods: The Premier database was queried from 2007–2011 for clinical and cost data for patients undergoing isoAVR. This de-identified database contains billing, hospital cost, and coding data from >600 US facilities with information from >25 million inpatient discharges. Expert rules were developed to identify patients with RAT and those with any sternal incision (aStern). Propensity matching created groups adjusted for patient differences. The impact of surgical approach on outcomes and costs was modeled using regression analysis and, where indicated, adjusting for hospital size and geographical differences. Results: AVR was performed in 27,051 patients. Analysis identified isoAVR by RAT (n = 1572) and by aStern (n = 3962). Propensity matching created two groups of 921 patients. RAT was more likely performed in southern hospitals (63% vs 36%; p < 0.01), teaching hospitals (66% vs 58%; p < 0.01) and larger hospitals (47% vs 30%; p < 0.01). There was significantly less blood product cost associated with RAT (

Totally Endoscopic Robotic Left Atrial Appendage Closure Demonstrates High Success Rate.

1381 vs

Isolated Lung Perfusion for Pulmonary Metastases

1912; p < 0.001). After adjusting for hospital differences, RAT was associated with lower cost than aStern (

The Coapsys Device: Technique and Results

38,769 vs

Can the learning curve of totally endoscopic robotic mitral valve repair be short-circuited?

42,656; p < 0.01). Conclusions: Outcomes analyses can be performed from hospital administrative collective databases. This real world analysis demonstrates comparable outcomes and less cost and ICU time with RAT for AVR.

Minimally invasive mitral surgery through right mini-thoracotomy under direct vision

OBJECTIVE The present study aimed to evaluate the effect of blood conservation strategies on patient outcomes after aortic surgery. DESIGN Retrospective cohort analysis of prospective data. SETTING University hospital. PARTICIPANTS Patients undergoing thoracic aortic surgery. INTERVENTIONS One hundred thirty-two consecutive high-risk patients (mean EuroSCORE 10.4%) underwent thoracic aortic aneurysm or dissection repair from January 2010 to September 2011. A blood conservation strategy (BCS) focused on limitation of hemodilution and tolerance of perioperative anemia was used in 57 patients (43.2%); the remaining 75 (56.8%) patients were managed by traditional methods. Mortality, major complications, and red blood cell transfusion requirements were assessed. Independent risk factors for clinical outcomes were determined by multivariate analyses. MEASUREMENTS AND MAIN RESULTS Hospital mortality was 9.8% (13 of 132). Lower preoperative hemoglobin was an independent predictor of mortality (p<0.01, odds ratio [OR] 1.7). Major complications were associated with perioperative transfusion: 0% complication rate in patients receiving<2 units of packed red blood cells versus 32.3% (20 of 62) in patients receiving ≥2 units. The blood conservation strategy had no significant impact on mortality (p = 0.4) or major complications (p = 0.9) despite the blood conservation patients having a higher incidence of aortic dissection and urgent/emergent procedures and lower preoperative and discharge hemoglobin. In patients with aortic aneurysms, BCS patients received 1.5 fewer units of red blood cells (58% reduction) than non-BCS patients (p = 0.01). Independent risk factors for transfusion were lower preoperative hemoglobin (p<0.01, OR 1.5) and lack of BCS (p = 0.02, OR 3.6). CONCLUSIONS Clinical practice guidelines for blood conservation should be considered for high-risk complex aortic surgery patients.