Brian Lima

Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures

2013;95:1-66 Ann Thorac Surg Vinod H. Thourani, E. Murat Tuzcu, John Webb and Mathew R. Williams Michael Reardon, T. Brett Reece, G. Russell Reiss, Eric E. Roselli, Craig R. Smith, Kodali, Samir Kapadia, Martin B. Leon, Brian Lima, Bruce W. Lytle, Michael J. Mack, Dewey, Richard S. DAgostino, Thomas G. Gleason, Katherine B. Harrington, Susheel Joseph E. Bavaria, Eugene H. Blackstone, Tirone E. David, Nimesh D. Desai, Todd M. Craig Miller, Patrick T. OGara, David M. Shahian, Hartzell V. Schaff, Cary W. Akins, Lars G. Svensson, David H. Adams, Robert O. Bonow, Nicholas T. Kouchoukos, D. Measures Aortic Valve and Ascending Aorta Guidelines for Management and Quality http://ats.ctsnetjournals.org/cgi/content/full/95/6_Supplement/S1 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Unplanned hospital readmissions after HeartMate II implantation: frequency, risk factors, and impact on resource use and survival.

OBJECTIVESnThe purpose of this study was to identify potential areas for quality improvement and cost containment. We investigated readmissions after HeartMate II left ventricular assist device (LVAD) implantation by characterizing their type, temporal frequency, causative factors, and resource use and survival after readmission.nnnBACKGROUNDnThe HeartMate II LVAD provides enhanced survival and quality of life to end-stage heart failure patients. Whether these improved outcomes are accompanied by a similar reduction in unplanned hospital readmissions is largely unknown.nnnMETHODSnFrom October 2004 to January 2010, 118 patients received a HeartMate II, of whom 92 were discharged on device support. Subsequent readmissions were analyzed using prospectively maintained clinical and financial databases.nnnRESULTSnForty-eight patients (52%) had 177 unplanned hospital readmissions, 87 non-LVAD- and 90 LVAD-associated. Reasons for non-LVAD-associated readmissions included medical management of comorbidities and progression ofxa0cardiac pathology (nxa0= 48), neuropsychiatric/psychosocial issues (nxa0= 22), and infections (nxa0= 17). Those for LVAD-associated readmissions included device component infection (nxa0= 51), management of nontherapeutic anticoagulation or device malfunction (nxa0= 22), and bleeding (nxa0= 15). Cumulative incidence of unplanned readmissions was higher (pxa0< 0.0001) for destination therapy than bridge-to-transplant patients (9/patient vs. 4/patient at 24 months). Cumulative hospital days overall were 25 and 42 at 12 and 18 months, respectively, and the costs were 18% and 29% of initial implantation costs. Increased number of unplanned readmissions was predictive of mortality.nnnCONCLUSIONSnUnplanned readmissions are common during HeartMate II support and negatively affect resource use and survival. Refining patient selection, especially in destination therapy patients, reducing infectious and bleeding complications, and increasing awareness about these devices might reduce unnecessary readmissions.

Aortic valve and ascending aorta guidelines for management and quality measures: executive summary.

The Society of Thoracic Surgeons Clinical Practice Guidelines are intended to assist physicians and other health care providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, these guidelines are subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.

Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: The role of intrathecal papaverine

OBJECTIVESnAn array of neuroprotective strategies has evolved to limit spinal cord injury during descending thoracic aneurysm and thoracoabdominal aortic aneurysm repair. This study prospectively assessed the neuroprotective impact of intrathecal papaverine added to other techniques in aortic aneurysm repairs.nnnMETHODSnFrom January 2002 to January 2010, 398 consecutive patients underwent descending thoracic aneurysm and thoracoabdominal aortic aneurysm repairs at Cleveland Clinic, 68 under hypothermic circulatory arrest. We focused on the remaining 330, in whom a combination of neuroprotective adjuncts was used intraoperatively to mitigate spinal cord ischemia. These included distal aortic perfusion with moderate hypothermia, cerebrospinal fluid drainage, and intrathecal papaverine. Two patient groups were discriminated according to whether intrathecal papaverine was (n = 250) or was not (n = 80) administered. Postoperative outcomes were analyzed from a prospectively maintained clinical database.nnnRESULTSnPreoperative patient characteristics and comorbidities were similar between groups. Extent of aortic disease was also similar: descending thoracic aneurysm (34% with papaverine vs 28%) and Crawford types I (25% vs 34%), II (27% vs 24%), III (13% vs 13%), and IV (2% vs 2.5%). Groups had similar in-hospital mortality (6.4% vs 11%; P = .11) and permanent stroke (4.4% vs 7.5%; P = .3). Permanent paraplegia (3.6% vs 7.5%; P = .01) and paraparesis (1.6% vs 6.3%; P = .01) were significantly lower in the intrathecal papaverine group.nnnCONCLUSIONSnAdding intrathecal papaverine to the neuroprotective protocol for descending thoracic aneurysm and thoracoabdominal aortic aneurysm repairs may enhance spinal cord perfusion and provide additional spinal cord protection.

Open, Hybrid, and Endovascular Treatment for Aortic Coarctation and Postrepair Aneurysm in Adolescents and Adults

BACKGROUNDnOpen, hybrid, and endovascular procedures are used for grown-up patients with aortic coarctation and complications after repair, an expanding population. We sought to characterize patients and procedures, assess early and late outcomes, and describe indications to guide treatment of these complex patients.nnnMETHODSnBetween May 1999 and January 2011, 110 patients underwent open (n=40), hybrid (n=11), or endovascular (n=59) repair of coarctation (n=43), recurrent aortic coarctation (n=42), or postrepair aneurysm (n=25). Mean age was 38±14 years. Sixty-eight had previous repairs (median 27 years earlier; range, 1 to 50). Twenty-two had prior cardiovascular operations other than coarctation and 50% had bicuspid valve. Fifty-nine concomitant procedures were performed in 45 patients (40%). Data were from the prospective database, chart review, and Social Security Death Index.nnnRESULTSnTechnical success was achieved in 100%, with no hospital deaths, no strokes, and no paraplegia. Complications were uncommon and included respiratory failure (n=2, 1.8%), and temporary renal failure (n=2, 1.8%). Twenty-two patients required reinterventions, but half of those were planned. There was no difference in occurrence of unplanned reintervention between approaches (endovascular 12%, hybrid 18%, open 12.5%). Length of stay was 4.8±4.8 days. Transcoarct gradient fell from 37.6±18 mm Hg preoperatively to 7.0±6.9 mm Hg in coarctation patients. Postrepair aneurysm patients had no late ruptures, and maximum diameter shrunk from 5.9±1.3 cm preoperatively to 4.8±1.3 cm. Estimated survival at 1, 5, and 8 years was 95%, 95%, and 90%, respectively.nnnCONCLUSIONSnCoarctation, recurrent coarctation, and postrepair aneurysm/pseudoaneurysm in adolescent and adult patients can be safely and effectively managed with open, hybrid, or endovascular techniques. Optimal results are achievable in this complex population of patients with a multimodality approach tailored to surgical indication and anatomy. All survivors of coarctation repair require lifelong surveillance.

Modified and “Reverse” Frozen Elephant Trunk Repairs for Extensive Disease and Complications After Stent Grafting

BACKGROUNDnThe frozen elephant trunk (FET) repair technique combines conventional arch repair with the patient under circulatory arrest with stent grafting and is increasingly being used to treat extensive thoracic aortic disease. This surgical approach is evolving, including its use for complications after thoracic aortic stent grafting - the so-called reversed frozen elephant trunk (RFET). We evaluated the safety and efficacy of FET and RFET operations in high-risk patients.nnnMETHODSnBetween July 2001 and December 2010, 31 patients underwent FET and 19 patients underwent RFET for extensive thoracic aortic disease. Causes included aneurysm (n=32), acute dissection (n=17), and rupture (n=1). Twenty-three cases (46%) were for urgent or emergency indications. Patient data and outcomes were collected through a prospectively maintained clinical database and 3-dimensional analysis of computed tomography (CT) scans. Outcomes were assessed using Kaplan-Meier methodology.nnnRESULTSnIn-hospital mortality was 8% (n=4, including 1 emergency RFET procedure for aortic rupture and 2 urgent FET procedures for symptomatic degenerative aneurysm). Stroke occurred in 5 patients (10%) and spinal cord injury in 4 patients (8%). Mean hospital stay was 14.3 days (range 4 to 67 days). Five endoleaks were observed (4 type II, 1 type I) requiring 2 endovascular reinterventions. Mean follow-up was 17 months (range, 1 to 76 months) and actuarial survival was 87% at 2 years.nnnCONCLUSIONSnFrozen elephant trunk repair is an effective surgical strategy for managing high-risk patients with extensive pathologic conditions of the thoracic aorta. The RFET approach is a feasible option for proximal aortic complications after previous descending stent grafting. Intermediate outcomes are reasonable for both approaches and further evaluation of these techniques is warranted.

Outcomes of axillary artery side graft cannulation for extracorporeal membrane oxygenation

OBJECTIVEnTo determine the safety, efficacy, and frequency of side graft axillary artery cannulation for extracorporeal membrane oxygenation support and compare it with other cannulation techniques.nnnMETHODSnFrom January 2001 to October 2011, 308 adult patients were supported with extracorporeal membrane oxygenation at a single center. In 81 patients (26.3%), the extracorporeal membrane oxygenation circuit was composed of an arterial inflow by a side graft sewn to the axillary artery. Of the 308 patients, 166 (53.9%) underwent femoral arterial cannulation and 61 (19.8%) underwent ascending aortic cannulation The pertinent variables and postprocedural events were retrospectively analyzed in this cohort of patients.nnnRESULTSnThe most common complication in the axillary artery group was hyperperfusion syndrome of the ipsilateral upper extremity (n = 20, 24.7%), followed by bleeding from the arterial outflow graft (n = 14, 17.3%). Lower extremity ischemia and fasciotomy were more frequent after femoral arterial cannulation (n = 27, 16%, and n = 18, 10.8%, respectively). The predictors for a poor in-hospital outcome for the entire group of patients were age and postoperative cerebral vascular accident. The cannulation method was not a predictor of in-hospital outcomes.nnnCONCLUSIONSnExtracorporeal membrane oxygenation support with side graft axillary artery technique was more frequently associated with hyperperfusion syndrome than other cannulation sites. Lower extremity ischemia and compartment syndrome was more common after femoral arterial cannulation.

Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial

OBJECTIVEnThe study objective was to perform a randomized trial of brain protection during total aortic arch replacement and identify the best way to assess brain injury.nnnMETHODSnFrom June 2003 to January 2010, 121 evaluable patients were randomized to retrograde (nxa0=xa060) or antegrade (nxa0=xa061) brain perfusion during hypothermic circulatory arrest. We assessed the sensitivity of clinical neurologic evaluation, brain imaging, and neurocognitive testing performed preoperatively and 4 to 6 months postoperatively to detect brain injury.nnnRESULTSnA total of 29 patients (24%) experienced neurologic events. Clinical stroke was evident in 1 patient (0.8%), and visual changes were evident in 2 patients; all had brain imaging changes. A total of 14 of 95 patients (15%) undergoing both preoperative and postoperative brain imaging had evidence of new white or gray matter changes; 10 of the 14 patients had neurocognitive testing, but only 2 patients experienced decline. A total of 17 of 96 patients (18%) undergoing both preoperative and postoperative neurocognitive testing manifested declines of 2 or more reliable change indexes; of these 17, 11 had neither imaging changes nor clinical events. Thirty-day mortality was 0.8% (1/121), with no neurologic deaths and a similar prevalence of neurologic events after retrograde and antegrade brain perfusion (22/60, 37% and 15/61, 25%, respectively; Pxa0=xa0.2).nnnCONCLUSIONSnAlthough this randomized clinical trial revealed similar neurologic outcomes after retrograde or antegrade brain perfusion for total aortic arch replacement, clinical examination for postprocedural neurologic events is insensitive, brain imaging detects more events, and neurocognitive testing detects even more. Future neurologic assessments for cardiovascular procedures should include not only clinical examination but also brain imaging studies, neurocognitive testing, and long-term assessment.

Outcomes of Simultaneous Liver Transplantation and Elective Cardiac Surgical Procedures

BACKGROUNDnMany centers are reticent to list patients for liver transplantation until coexistent cardiac disease is surgically corrected. Previous studies have documented considerable morbidity and mortality in liver failure patients undergoing cardiac operations. This study examined whether elective cardiac operations at the time of hepatic transplantation would yield enhanced outcomes.nnnMETHODSnBetween July 1999 and June 2010, 10 patients underwent simultaneous liver transplantation and elective cardiac operations at a single institution. Postoperative outcomes were analyzed using a prospectively maintained database.nnnRESULTSnThe 10 patients were men (mean age, 59.8 ± 8.3 years): 7 were in Child-Pugh class B and 3 were in class C. Mean Model for End-Stage Liver Disease score was 17.0 ± 5.8. Cardiac operations included coronary artery bypass grafting in 1, aortic valve replacement in 4, coronary artery bypass grafting and aortic valve replacement in 3, coronary artery bypass grafting and mitral valve repair in 1, and tricuspid valve repair in 1. In-hospital mortality was 20%. Mean postoperative length of stay was 23 ± 8 days. Actuarial survival at 3 years was 70%.nnnCONCLUSIONSnSurvival was modestly improved relative to that observed in previous studies of advanced liver failure patients undergoing heart operations without concomitant hepatic replacement. Moreover, the medium-term survival outcomes approach those documented with liver transplant alone. Further studies are warranted with this combined surgical strategy to determine if such an approach would be routinely preferable to staged repair of cardiac pathology and liver transplant.

Management of Extensive Intracardiac Thombosis in a Patient with Polycythemia Vera Undergoing Coronary Artery Bypass Grafting

Abstractu2002 Polycythemia vera (PV) is a chronic myeloproliferative disorder with a predilection for thrombotic complications in affected patients. Intracardiac thrombosis is a rare manifestation of this disease, as documented in only a few published cases. In this report, we describe a PV patient who suddenly developed extensive thrombosis within all four cardiac chambers and severe ventricular dysfunction during a coronary artery bypass procedure. We also detail the intraoperative salvage maneuvers implemented in this case, which included deep hypothermic circulatory arrest with retrocerebral perfusion and four chamber thrombectomy. (J Card Surg 2012;27:320–322)