David W. Yaffee

Management of blood transfusion in aortic valve surgery: impact of a blood conservation strategy.

BACKGROUND There are limited data in the literature concerning the effect of a blood conservation strategy (BCS) on aortic valve replacement (AVR) patients. METHODS From 2007 to 2011, 778 patients underwent AVR at a single institution. During this period, a multidisciplinary BCS was initiated with emphasis on limiting intraoperative hemodilution, tolerance of perioperative anemia, and blood management education for the cardiac surgery care providers. RESULTS Mortality was 3.0% (23 of 778) overall and 1.7% (9 of 522) for isolated first-time AVR. There was no difference in rates of mortality (p = 0.5) or major complications (p = 0.4) between the pre-BCS and post-BCS groups; however, the BCS was associated with a lower risk of major complications (odds ratio, 1.7; p = 0.046) by multivariable analysis. The incidence of red blood cell (RBC) transfusion decreased from 82.9% (324 of 391) to 68.0% (263 of 387; p < 0.01). Of those patients who did not receive any day-of-operation RBC transfusions, 64.5% (191 of 296) did not receive any postoperative RBC transfusions. Lower risk of RBC transfusion was associated with isolated AVR (p < 0.01), a minimally invasive approach (p < 0.01), and BCS (p < 0.01), whereas a greater risk of RBC transfusion was associated with older age (p < 0.01), prior cardiac operation (p = 0.01), female sex (p < 0.01), and smaller body surface area (p < 0.01). Day-of-operation RBC transfusion of 2 units or more was associated with increased deaths (p = 0.01), prolonged intubation (p < 0.01), postoperative renal failure (p = 0.01), and increased incidence of any complication (p < 0.01). CONCLUSIONS Perioperative BCS reduced RBC transfusion in AVR patients without an increase in mortality or morbidity. Guidelines for BCS in routine cardiac operations should be extended to AVR patients.

Systolic anterior motion of the mitral valve: A 30-year perspective

OBJECTIVE Systolic anterior motion (SAM) can occur after mitral valve repair (MVr), most frequently in patients with degenerative valve disease. Our initial observations (1981-1990) revealed that most patients with SAM can be successfully treated medically. Here the authors review the last 16 years of their experience with SAM after MVr. METHODS Between January 1996 and October 2011, 1918 patients with degenerative mitral valve disease underwent MVr at our institution. We performed a retrospective analysis of SAM in this patient population. RESULTS The incidence of SAM was 4.6% (89 of 1918) overall, 4.0% (77 of 1906) in patients who did not have SAM preoperatively (de novo). Compared with our previously published report, the incidence of SAM decreased from 6.4% to 4.0% (P = .03). Hospital mortality was 2.0% (38 of 1918) overall, 1.3% (14 of 1078) for isolated MVr. One patient with de novo SAM (1 of 77; 1.3%) died after emergency MVr. All patients with de novo SAM were successfully managed conservatively with intravenous fluids, α agonists, and/or β blockers. A higher incidence of SAM was associated with a left ventricular ejection fraction greater than 60% (P = .01), posterior leaflet resection (P = .048), and hypertrophic obstructive cardiomyopathy (P < .01). The incidence of SAM was lower in patients who underwent device mitral annuloplasty with a semirigid posterior band compared with a complete ring (P = .03). CONCLUSIONS In the more recent era, SAM occurs one-third less frequently after repair of degenerative mitral valve disease. Use of an incomplete annuloplasty band rather than a complete ring is associated with a lower incidence of SAM. The mainstay treatment of SAM continues to be medical management.

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

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.

Editorial analysis: impact of perfusion strategy on stroke risk for minimally invasive cardiac surgery.

The move from full median sternotomy to less invasive approaches for valvular heart surgery has been driven by the desire to reduce post-operative pain and surgical trauma and to improve cosmesis and patient satisfaction [1]. Non-sternotomy incisions, however, can limit exposure to the ascending aorta. This raises the question of whether to attempt a technically more challenging ascending aortic cannulation using advanced cannulation technology/techniques, or perform retrograde arterial perfusion via a standard femoral approach [2]. A recent Society of Thoracic Surgeons (STS) database publication associated ‘less invasive mitral valve (LIMV) operation(s)’ with a nearly 2-fold increase in the risk of permanent stroke [3]. While this analysis was hampered by its equation of LIMV with femoral perfusion, it did raise the spectre that increased stroke risk was associated with a femoral perfusion strategy. Over the past 15 years, our institution has employed different perfusion techniques for our less invasive procedures. Our initial foray into right-thoracotomy incisions utilized retrograde perfusion via the ‘port access’ platform. With an informal strategy of intraoperative echocardiographic analysis of the aortic arch and the descending aorta, we avoided the use of femoral perfusion when we believed that there was significant atherosclerotic burden. The results from this approach were excellent as demonstrated by the evaluation of our first 714 minimally invasive mitral valve procedures [4]. In this cohort, where 30% of patients were >70 years of age, 15% were reoperations and 12% were multivalve operations, femoral perfusion was used in nearly 80% of patients, with a 2.9% incidence of stroke. Although satisfied with these results, we realized that there was a significant, primarily geriatric patient population which was underserved by this selective approach. As such, we developed greater facility with central aortic cannulation through a mini-thoracotomy incision until this became our ‘go-to’ approach for the majority of our minimally invasive mitral valve procedures, regardless of age. These minimally invasive incision patients have been the subject of recent reports. At the 2011 STS meeting, we presented an analysis of 3180 isolated, non-reoperative valve procedures performed at our institution between 1995 and 2007. The overall stroke rate was 2.2%, with increased stroke risk associated with an atherosclerotic aorta, cerebrovascular disease, emergent operation, ejection fraction <30% or retrograde perfusion (P < 0.05 for each), but not with incision location (P = 0.82). Additionally, the association of retrograde perfusion became insignificant when analysing patients who are 50-years old or younger [5]. These results mirror those of our previous cohort of patients undergoing reoperative mitral valve procedures, which revealed that retrograde perfusion was the only independent risk factor for stroke (odds ratio 4.4; P = 0.001) [6]. Subsequently, we presented a focused report on a more homogeneous subset of 1282 first-time, isolated mitral valve operations performed through a right anterior mini-thoracotomy over a 12-year period [7]. This homogeneity allowed us greater discriminatory power to analyse the specific patient factors associated with an increased risk of stroke. The only significant risk factor interaction for neurologic complication identified was the use of retrograde perfusion in patients with high-risk comorbidities: peripheral vascular disease, cerebrovascular disease, atherosclerotic aortas or dialysis dependence. Our current clinical practice attempts to restrict retrograde arterial perfusion to those surgical scenarios where there is a very limited central aortic access, such as patients undergoing robotic mitral valve surgery, or a hostile mediastinum. In these cases, the question remains: what preoperative evaluation is needed prior to performing retrograde perfusion? Our data suggest that retrograde perfusion remains a viable option for younger patients without vascular co-morbidities. In older patients or those with the risk factors discussed above, we currently recommend performing a computed tomography angiography of the descending aorta with distal runoff in addition to an intraoperative transoesophageal echocardiographic assessment of the thoracic aorta. Such an approach has been shown to be efficacious by Murphy et al. [8], who demonstrated a 1.6% stroke rate using retrograde perfusion in similarly screened patients undergoing robotic cardiac procedures. Minimally invasive valve surgery with antegrade perfusion has a low risk of neurological complications and has excellent outcomes. Retrograde perfusion in older patients with significant vascular co-morbidities is associated with an increased risk of stroke. The vast majority of our patients currently undergo heart valve procedures through a right anterior mini-thoracotomy with

Regional Changes in Coaptation Geometry After Reduction Annuloplasty for Functional Mitral Regurgitation

BACKGROUND While it is known that band annuloplasty for functional mitral regurgitation (FMR) improves leaflet coaptation, the effect on regional coaptation geometry has not previously been well defined. We used three-dimensional transesophageal echocardiography (3D-TEE) to analyze the regional effects of semirigid band annuloplasty on annular geometry and leaflet coaptation zones of patients with FMR. METHODS Sixteen patients with severe FMR underwent a semirigid band annuloplasty. Intraoperative full volume 3D-TEE datasets were acquired pre valve and post valve repair. Offline analysis assessed annular dimensions and regional coaptation zone geometry. The regions were defined as R1 (A1-P1), R2 (A2-P2), and R3 (A3-P3); coaptation distance, coaptation depth, and coaptation length were measured in each region. Differences were analyzed with repeated measures within a general linear model. RESULTS Band annuloplasty decreased mitral regurgitation grade from 3.7 to 0.1 (scale 0 to 4). Annular septolateral dimension (p<0.01) and coaptation distance (p<0.01) decreased significantly in all regions. Likewise, anterior and posterior leaflet coaptation lengths increased in all regions (p<0.01 and p=0.05, respectively), with region 2 showing the greatest increase (p=0.01). Changes in coaptation depth were not significant. CONCLUSIONS Semirigid band annuloplasty for FMR produces significant regional remodeling of leaflet coaptation zones, with region 2 showing the greatest increase in leaflet coaptation length. This regional analysis of annular geometry and leaflet coaptation creates a framework to better understand the mechanisms of surgical success or failure of annuloplasty for FMR.

Cardiovascular Surgery in the Elderly

The elderly population is the fastest growing demographic in Western countries. As the population ages, the incidence of age-related comorbidities such as diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, renal disease, cerebrovascular disease, and cardiovascular disease increases. With cardiovascular disease occurring in approximately one-quarter of the population over the age of 75 years and more than half of all cardiac procedures performed on this age group, the number of potential elderly surgical candidates is increasing. However, data suggest that old age is associated with increased morbidity and mortality following cardiac surgery. Over the past 2 decades, improvements in myocardial protection, extracorporeal circulation, anesthesia, and surgical techniques have significantly reduced the morbidity and mortality associated with cardiac surgery. Although most prospective studies exclude elderly patients, data from large retrospective studies and subgroup analyses suggest that cardiac surgery is a viable option for many elderly patients with cardiovascular disease, with good outcomes observed in reasonable-risk candidates; moreover, there are a growing number of available less-invasive options for them when surgical risk becomes prohibitive. In this article, we discuss the current state of cardiovascular surgery in the elderly as well as emerging technologies on the horizon.

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

Objective In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates. Methods Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4–0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm. Results Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow. Conclusions We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.

Progressive design concepts in off-pump left ventricular remodeling mitral valve repair devices.

Functional mitral regurgitation (FMR) occurs in the myopathic ventricle when papillary muscle displacement with leaflet tethering and/or annular dilatation causes valvular insufficiency. The resultant left ventricular (LV) volume overload then potentiates further negative remodeling. Current surgical management of FMR involves either mitral valve repair (MVr) or mitral valve replacement (MVR), each of which are associated with significant perioperative risk and poor late outcomes. This has led to the development of novel methods of reshaping the left ventricle and mitral valve to treat FMR while minimizing the operative risk and preventing negative ventricular remodeling. While off-pump devices for mitral leaflet repair including percutaneous mitral clips, trans-apical neochordae and percutaneous mitral replacement devices are under investigation, this report reviews the current status of both passive and active off-pump ventricular and mitral annular reshaping devices.

Rethinking the gold standard of correction for paravalvular leak: Why correct when you can prevent?

From the Department of Cardiothoracic Surgery, New York University School of Medicine, New York, NY. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication July 27, 2016; accepted for publication July 29, 2016; available ahead of print Sept 20, 2016. Address for reprints: Eugene A. Grossi, MD, NYUMedical Center, 530 First Ave, Suite 4K, NewYork, NY 10016 (E-mail: eugene.grossi@nyumc.org). J Thorac Cardiovasc Surg 2016;152:e103-4 0022-5223/

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

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.07.057