Harold M. Burkhart

Mitral valve repair using robotic technology: Safe, effective, and durable.

The most recent American College of Cardiology/American Heart Association heart valve guidelines recommend that prompt surgical correction of severe degenerative mitral valve regurgitation, ideally mitral valve repair, should be performed to decrease the risks of long-term mortality and heart failure risks associated with this condition. Mitral valve repair performed using a minimally invasive robotic approach can now be successfully carried out in nearly all cases of degenerative disease with very low risks of stroke or death. Experienced groups have further shown specific advantages of robotic mitral valve repair compared with conventional approaches, including reduced blood loss, lower risks of infection and atrial fibrillation, shorter hospital length of stay, quicker return to normal activities, and a superior cosmetic result. Herein, we discuss the current status of robotic mitral valve repair including indications, technical advances, safety, effectiveness, and durability.

Perioperative mortality is the Achilles heel for cardiac transplantation in adults with congenital heart disease: Evidence from analysis of the UNOS registry.

Adults with congenital heart disease may present with end‐stage heart failure necessitating orthotopic heart transplant (OHT). We sought to review the United Network for Organ Sharing (UNOS) experience with this unique cohort focusing on surgical outcomes and survival.

The Fontan Operation: Is Timing Everything?

Since the introduction of the Fontan operation over 4 decades ago, surgical and medical management strategies have evolved to improve outcomes and give hope to the patients with complex single ventricle anomalies. Unfortunately, along with these new treatment successes, another group of problems has become more evident stimulating us to rethink our current management with a new focus on long-term outcomes and quality of life. The primary detrimental physiologic conditions that Fontan operation imposes on the patient are central venous hypertension and reduced cardiac output. 1 Hepatic dysfunction and protein losing enteropathy are felt to be related to the Fontan circulation with evidence that they may be a timedependent phenomena related to the time of Fontan operation. 2 In addition, the ventricle is abnormal with evidence of diastolic dysfunction becoming apparent in most. 3 With these sequelae in mind, there exists a controversy as to the best timing for completion Fontan. Some have adopted the belief that patients with total cavopulmonary connection have a limited amount of time before these issues become evident. Followers of the “ticking clock” theory would argue for delaying the Fontan operation until later in life in the hopes of postponing the long-term complications. Others argue that it may not only be time-dependent, and that performing an early Fontan operation may result in a better long-term single ventricle patient. Forsdick et al 4 present the outcomes of 45 patients who underwent a Fontan operation from 1976-2006. The average age of the patient at time of Fontan was 18-year old. Importantly, this cohort of patients represents all the adolescent and adult patients who underwent total cavopulmonary configuration in Australia or New Zealand. Data were available for 87% of the patients with a mean follow-up time of 15.5 years. They reported an early mortality of 6% and late mortality of 18%. Although these numbers are not significantly different than other reported series of adult Fontan patients, 5 they appear to be strikingly different than what has been reported by the same group for Fontan completion in a younger population. 6 They conclude that the results of performing a Fontan

The “right” way to repair recoarctation after the Norwood operation

From the Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Aug 8, 2016; accepted for publication Aug 8, 2016. Address for reprints: Harold M. Burkhart, MD, Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, WP-2230, Oklahoma City, OK 73105 (E-mail: Harold-burkhart@ouhsc.edu). J Thorac Cardiovasc Surg 2016;-:1-2 0022-5223/

Closing in on the perfect Fontan

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.08.009

The Ross operation: Are we doing enough?

Since the introduction of the Fontan operation more than 4 decades ago, many modifications to the operation have occurred and have been debated in the name of finding the ‘‘perfect’’ Fontan. Along the way, the ‘‘Ten Commandments’’ for a Fontan have been reduced to 4 or 5. Valves have been repaired, subaortic and aortic arch obstructions have been relieved, and pulmonary architecture has been altered, all in hopes of producing a perfect Fontan circulation. Although progress has certainly been made with the surgical modifications, controversy still exists. Extracardiac or lateral tunnel, fenestration or no fenestration, beating heart or cardiac arrest, and even on-pump or off-pump are just of few of the issues currently debated. The one thing in common with regard to these controversies is that excellent surgical results can be expected in the current era. Dabal and colleagues present a 2-decade review of their experiencewith 207Fontan procedures performedwith an internal or, more recently, external polytetrafluoroethylene conduit. The patient group was a complex group. Tricuspid atresia and double-inlet left ventricle accounted for 42%, whereas hypoplastic left heart syndrome accounted for only 9% because representation of these cases was limited to the last decade of the study period. Earlymortality was excellent, decreasing from 7% in the earlier era to 0% in the last 6 years of the review.With robust long-term follow-up, the survival was noted to be 77% at 20 years. Importantly and uniquely, during this period no late phase of increasing risk was identified. Furthermore, freedom from any reoperation, including transplant, was greater than 90% at 20 years. Dabal and colleagues should be congratulated on their surgical results in constructing a ‘‘perfect’’ Fontan pathway that has provided excellent palliation in the first 1 to 2 decades. One area in which the review falls short is in the discussion of their Fontan procedure exclusion criteria.