Igor Gosev

Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients

BACKGROUND Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period. METHODS Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients. RESULTS Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018). CONCLUSIONS This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.

Late outcomes comparison of nonelderly patients with stented bioprosthetic and mechanical valves in the aortic position: A propensity-matched analysis

OBJECTIVE Our study compares late mortality and valve-related morbidities between nonelderly patients (aged <65 years) undergoing stented bioprosthetic or mechanical valve replacement in the aortic position. METHODS We identified 1701 consecutive patients aged <65 years who underwent aortic valve replacement between 1992 and 2011. A stented bioprosthetic valve was used in 769 patients (45%) and a mechanical valve was used in 932 patients (55%). A stepwise logistic regression propensity score identified a subset of 361 evenly matched patient-pairs. Late outcomes of death, reoperation, major bleeding, and stroke were assessed. RESULTS Follow-up was 99% complete. The mean age in the matched cohort was 53.9 years (bioprosthetic valve) and 53.2 years (mechanical valve) (P=.30). Fifteen additional measurable variables were statistically similar for the matched cohort. Thirty-day mortality was 1.9% (bioprosthetic valve) and 1.4% (mechanical valve) (P=.77). Survival at 5, 10, 15, and 18 years was 89%, 78%, 65%, and 60% for patients with bioprosthetic valves versus 88%, 79%, 75%, and 51% for patients with mechanical valves (P=.75). At 18 years, freedom from reoperation was 95% for patients with mechanical valves and 55% for patients with bioprosthetic valves (P=.002), whereas freedom from a major bleeding event favored patients with bioprosthetic valves (98%) versus mechanical valves (78%; P=.002). There was no difference in stroke between the 2 matched groups. CONCLUSIONS In patients aged <65 years, despite an increase in the rate of reoperation with stented bioprosthetic valves and an increase in major bleeding events with mechanical valves, there is no significant difference in mortality at late follow-up.

Minimally invasive aortic valve replacement versus aortic valve replacement through full sternotomy: the Brigham and Women’s Hospital experience

BACKGROUND Minimally invasive aortic valve surgery (mini AVR) is a safe and effective treatment option at many hospital centers, but there has not been widespread adoption of the procedure. Critics of mini AVR have called for additional evidence with direct comparison to aortic valve replacement (AVR) via full sternotomy (FS). METHODS Our mini AVR approach is through a hemi-sternotomy (HS). We performed a propensity-score matched analysis of all patients undergoing isolated AVR via FS or HS at our institution since 2002, resulting in 552 matched pairs. Baseline characteristics were similar. Operative characteristics, transfusion rates, in-hospital outcomes as well as short and long term survival were compared between groups. RESULTS Median cardiopulmonary bypass and cross clamp times were shorter in the HS group: 106 minutes [inter-quartile ranges (IQR) 87-135] vs. 124 minutes (IQR 90-169), P≤0.001, and 76 minutes (IQR 63-97) vs. 80 minutes (IQR 62-114), P≤0.005, respectively. HS patients had shorter ventilation times (median 5.7 hours, IQR 3.5-10.3 vs. 6.3 hours, IQR 3.9-11.2, P≤0.022), shorter intensive care unit stay (median 42 hours, IQR 24-71 vs. 45 hours, IQR 24-87, P≤0.039), and shorter hospital length of stay (median 6 days, IQR 5-8 vs. 7 days, IQR 5-10, P≤0.001) compared with the FS group. Intraoperative transfusions were more common in FS group: 27.9% vs. 20.0%, P≤0.003. No differences were seen in short or long term survival, or time to aortic valve re-intervention. CONCLUSIONS Our study confirms the clinical benefits of minimally invasive AVR via HS, which includes decreased transfusion requirements, ventilation times, intensive care unit and hospital length of stay without compromising short and long term survival compared to conventional AVR via FS.

Right Ventricular Perforation and Pulmonary Embolism With Polymethylmethacrylate Cement After Percutaneous Kyphoplasty

A 58-year--old woman was referred to our center for further workup and treatment of a probable polymethylmethacrylate (PMMA) embolism to the right ventricle (RV) and right pulmonary artery. The patient’s medical history included hypertension, hypothyroidism, hyperlipidemia, and anxiety. She developed lower back pain ≈1 month before admission and was diagnosed with multiple compression fractures. Ten days before admission, the patient underwent percutaneous kyphoplasty of the T11, T12, and L1 vertebral bodies. A biopsy during that procedure revealed multiple myeloma as the underlying cause of the fractures. No vascular abnormalities were noticed at that time. A day before transfer she was readmitted with chest pain and shortness of breath. She was noted to have diffuse ST segment elevations on her ECG and mildly elevated cardiac troponin. Coronary angiography did not show evidence of obstructive coronary disease. However, fluoroscopy during coronary angiography showed foreign material in the RV and the pulmonary artery (Figure 1 and online-only Data Supplement Movie I). A computed tomography demonstrated foreign material in the RV and the pulmonary artery with a free wall perforation (Figure 2 and …

Cardiac myxoma the great imitators: Comprehensive histopathological and molecular approach

Cardiac myxomas are rare benign and slowly proliferating neoplasms of uncertain histogenesis with heterogeneous histomorphology and variable and sometimes clinically quite malignant pathological manifestations. Majority of cardiac myxoma occur sporadically while a relatively small proportion of diagnosed cases develop as a part of Carney complex syndrome with established familial pattern of inheritance. Although histologically indistinguishable these two forms of cardiac myxoma exhibit distinct cytogenetic make-up and apparent pathological differences important for their clinical presentation and prognosis. Additional problem is presented with secondary lesions with more aggressive histology and significantly faster cell proliferation suggesting their successive malignant alteration. Surgical resection of cardiac myxoma is currently the only treatment of choice. However, to avoid potentially hazardous operating procedures and possible postoperative complications and to prevent recurrence of the neoplastic lesions it is necessary to develop alternative approaches and identify a possible drug targets for their successful pharmacological treatment. Due to the rarity of the disease, a small number of cases in one institution and lack of comprehensive experimental data particularly concerning the cases of metastatic dissemination and secondary lesions with malignant nature, a comprehensive multi-institutional approach is required for better understanding of their molecular pathology and illumination of key molecular, genetic as well as epigenetic markers and regulatory pathways responsible for their development. In this article we provide comprehensive pathohistological, molecular and cytogenetic overview of sporadic cardiac myxoma cases restating the major hypothesis concerning their histogenesis and emphasizing potential approaches for their further reexamination.

The safety of deep hypothermic circulatory arrest in aortic valve replacement with unclampable aorta in non-octogenarians

OBJECTIVES Aortic valve replacement (AVR) in patients with severely atherosclerotic aortas (porcelain aorta) presents a significant technical challenge. Two strategies are deep hypothermic circulatory arrest (DHCA) during conventional surgery and transcatheter aortic valve replacement (TAVR). The aim of this study was to examine the outcomes in patients who underwent DHCA for AVR with a porcelain aorta to identify whether older patients are more suitable for TAVR. METHODS Between October 2004 and December 2012, 122 patients underwent AVR using DHCA for atherosclerotic aorta. Patients with concomitant valve surgery were excluded. Overall, 63.9% (78/122) were of age <80 (non-octogenarian group, NOG) and 36.1% (44/122) were >80 (octogenarian group, OG). Of the total cohort, 62.3% (76/122) had concomitant coronary artery bypass graft surgery. RESULTS The mean age for the whole cohort was 75.7 ± 8.5 years; 70.2 ± 8.1 years for the NOG and 83.4 ± 2.6 years for the OG (P = 0.001). The OG had a higher rate of preoperative renal failure (20.5%, 9/44 vs 7.7%, 6/78, P = 0.048) and trends towards a greater history of cerebrovascular disease (9.1%, 4/44 vs 1.3%, 1/78, P = 0.056), but fewer reoperations (6.8%, 3/44 vs 19.2%, 15/78, P = 0.069). Cardiopulmonary bypass time, aortic cross-clamp time and circulatory arrest time were similar between the two groups. Postoperative complication rates were similar except for permanent stroke (OG 18.2%, 8/44 vs NOG 6.4%, 5/78, P = 0.065). The overall operative mortality rate was 8.2% (10/122); however, the OG had significantly higher operative mortality compared with the NOG (15.9%, 7/44 vs 3.8%, 3/78, P = 0.035). One- and 5-year survival rates were 88.9 and 79.3% for the NOG versus 75.0 and 65.9% for the OG (P = 0.027), respectively. CONCLUSIONS Postoperative neurological events and operative mortality were, respectively, 3- and 4-fold higher in octogenarians undergoing AVR using DHCA. Such patients may represent suitable candidates for TAVR if favourable outcomes are demonstrated in patients with atherosclerotic aortas. Surgical AVR remains the standard treatment option with excellent outcomes for patients <80 years old with unclampable aortas.

Sharing the Care of Mechanical Circulatory Support Collaborative Efforts of Patients/Caregivers, Shared-Care Sites, and Left Ventricular Assist Device Implanting Centers

Left ventricular assist devices (LVADs) improve longevity, as well as functional capacity and quality of life in patients with medically refractory heart failure.1–5 During the 6 years since the US Food and Drug Administration approval of the first commercially available continuous flow LVAD in 2008, the number of patients supported by these devices has grown exponentially. The most recent report from the Interagency Registry for Mechanically Assisted Circulatory Support recorded nearly 2500 North American LVAD implants in 2013 at >150 implanting centers.6 Approximately 40% of LVADs are implanted as an indefinite form of support (ie, destination therapy [DT]), and nearly half of patients are surviving >4 years.6 This combination of improved survival and evolving implant strategies has led to an increasing number of LVAD recipients being integrated into the community and we are observing the growth of an ambulatory LVAD population with a unique set of clinical needs. There are 2 predominant strategies of LVAD implantation. Patients who are not eligible for transplantation because of issues such as advanced age may be considered for an LVAD as DT, implying that they will live the rest of their lives with the LVAD. This is in contrast to patients who undergo LVAD implantation as a temporary support device, to support them while awaiting transplantation. This later strategy is defined as a bridge-to-transplantation, following which, the device will be explanted. Centers implanting LVADs without concomitant transplant programs (designated DT centers) have emerged to provide this therapy, averting the need for travel to more distant transplant centers. Such DT centers operate in conjunction with a VAD/transplant partner in the care of patients awaiting transplantation. Because LVAD implant centers are frequently remotely located from the patients that they serve, a model of shared-care has developed, whereby the continued care of …

Should Moderate-to-Severe Tricuspid Regurgitation be Repaired During Reoperative Left-Sided Valve Procedures?

The risks vs benefits of tricuspid valve (TV) surgery in reoperative patients requiring left-sided valve surgery and moderate-to-severe tricuspid regurgitation is unclear. We compared patients with and without concomitant TV surgery. A total of 200 patients with moderate-to-severe TV regurgitation had reoperative left-sided valve procedures from January 2002 to April 2014; 75 with TV intervention (TVI) and 125 with no tricuspid intervention (TVN). Propensity-matched cohorts of 60 TVI and 60 TVN patients were compared. Outcomes included New York Heart Association class, TV regurgitation and survival. TVI patients were younger (66 ± 15 vs 72 ± 13 years, P < 0.001), had more cardiogenic shock (6 of 75, vs 0 of 125, P < 0.001) and mitral valve surgery (60 of 75 vs 69 of 125, P < 0.001). Propensity matching yielded 60 pairs of TVI cases and TVN controls. Matched groups were comparable in age (TVI = 67 ± 13 vs TVN 68 ± 14 years, P = 0.67), cardiogenic shock (2 vs 0, P = 0.50), and mitral valve surgery (15 each, P = 1.0). Operative mortality was 2 of 60 in TVI vs 10 of 60 TVN (P = 0.27). Median follow-up was 4.4 years. Follow-up rates of New York Heart Association class III-IV were similar (12 of 60 for TVI vs 16 of 60 TVN, P = 0.52). Kaplan-Meier analysis indicated improved event-free survival for TVI patients (6 years, 95% CI: 4.8-7.2 years vs 8 years, 95% CI: 6.7-9.3 years for TVN, P = 0.030). There was a trend towards increased TR at follow-up in patients with valve repair alone vs annuloplasty (P = 0.15). TV surgery was performed more often in higher-risk patients. Matched case-control analyses showed TVI was associated with improved midterm outcomes. Our data suggest that annuloplasty was preferable to TV repair alone.

Early Structural Valve Deterioration of the Mitroflow Aortic Bioprosthesis

There has been a trend toward more frequent use of bioprosthetic valves, especially in the young generations, over the last decade.1,2 According to the Society of Thoracic Surgeons database, use of bioprosthetic valve increased from 44% in 1996 to 78% in 2006 in North America.1 Freedom from warfarin use and restrictions on diet and activities make bioprosthetic valves more attractive and popular, and multiple reports have shown that choosing a bioprosthetic valve does not decrease survival despite the increased rate of reoperation.3,4 Article see p 2012 The Mitroflow aortic prosthesis (Sorin Group Inc) is one of the most frequently used bioprostheses, with >100 000 implanted worldwide.5 The bovine pericardium is mounted externally around the stent, which maximizes the flow relative to the stent size. The valve is placed in the supra-annular position compared with the intra-annular position in some of the other bioprostheses. These characteristics allow superior valve hemodynamics in the Mitroflow aortic valve, especially in those with a small aortic annulus (19 and 21 mm)6; therefore, the Mitroflow aortic valve is considered an ideal valve for patients with a small aortic root. The Achilles heel of the bioprosthetic valve is structural valve deterioration (SVD). Cusp tears and thickening, calcification, pannus formation, and thrombus lead to deterioration of the valve,7 which is the leading reason for reoperation in bioprosthetic valves. The rate of SVD differs among ages; valves implanted in younger patients degenerate faster. For patients >65 years of age, the 10-year freedom from SVD in new pericardial valves is typically >90%.8 In this issue of Circulation , Senage et al9 strike a note of warning …

The 2014 American Heart Association/American College of Cardiology guideline for the management of patients with valvular heart disease: A changing landscape

The American Heart Association (AHA) and American College of Cardiology (ACC) have updated the practice guidelines for the treatment of patients with valvular heart disease (VHD). The writing committee and task force members were experts in all aspects of valvular disease and included representatives from the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, American Society of Echocardiography, and surgical representatives from The American Association for Thoracic Surgery and Society of Thoracic Surgery (STS). Importantly, the writing committee members were free of industry affiliations. The original AHA/ACC VHD guidelines were released in 1998, revised in 2006, and updated in 2008. The recent growth in therapeutic options for VHD requires the incorporation of evolving techniques and current evidence to determine best practice. With the expansion of transcatheter and minimally invasive valve surgery, the question is not simply should we intervene, but how and when. To outline concomitant nonsurgical therapeutic advances, the Task Force coined the phrase guideline-directed medical therapy ‘‘to represent optimal medical therapy as defined by [the] ACC/AHA guideline (primarily class I)–recommended therapies.’’ Thus, the current guidelines reflect updates in medical and surgical advances, with new sections summarizing the role of transcatheter aortic valve replacement (TAVR) and transcatheter approaches for the mitral valve. Evolving approaches for aortic aneurysms and valve type choices are also discussed. For severe aortic stenosis, surgical AVR remains a class I, level of evidence A, recommendation for low or intermediate surgical risk candidates meeting the criteria for valve replacement. Drawing from several large, multiinstitutional, randomized controlled trials, the guidelines state that ‘‘TAVR is recommended in patients who meet an indication for AVR who have a prohibitive risk for