Julius I. Ejiofor

Are homografts superior to conventional prosthetic valves in the setting of infective endocarditis involving the aortic valve

BACKGROUND Surgical dogma suggests that homografts should be used preferentially, compared with conventional xenograft or mechanical prostheses, in the setting of infective endocarditis (IE), because they have greater resistance to infection. However, comparative data that support this notion are limited. METHODS From the prospective databases of 2 tertiary academic centers, we identified 304 consecutive adult patients (age ≥17 years) who underwent surgery for active IE involving the aortic valve (AV), in the period 2002 to 2014. Short- and long-term outcomes were evaluated using propensity scores and inverse-probability weighting to adjust for selection bias. RESULTS Homografts, and xenograft and mechanical prostheses, were used in 86 (28.3%), 139 (45.7%), and 79 (26.0%) patients, respectively. Homografts were more often used in the setting of prosthetic valve endocarditis (58.1% vs 28.8%, P = .002) and methicillin-resistant Staphylococcus (25.6% vs 12.1%, P = .002), compared with conventional prostheses. Early mortality occurred in 17 (19.8%) in the homograft group, and 20 (9.2%) in the conventional group (P = .019). During follow-up (median: 29.4 months; interquartile-range: 4.7-72.6 months), 60 (19.7%) patients died, and 23 (7.7%) experienced reinfection, with no significant differences in survival (P = .23) or freedom from reinfection rates (P = .65) according to the types of prostheses implanted. After adjustments for baseline characteristics, using propensity-score analyses, use of a homograft did not significantly affect early death (odds ratio 1.61; 95% confidence interval [CI], 0.73-3.40, P = .23), overall death (hazard ratio 1.10; 95% CI, 0.62-1.94, P = .75), or reinfection (hazard ratio 1.04; 95% CI, 0.49-2.18, P = .93). CONCLUSIONS No significant benefit to use of homografts was demonstrable with regard to resistance to reinfection in the setting of IE. The choice among prosthetic options should be based on technical and patient-specific factors. Lack of availability of homografts should not impede appropriate surgical intervention.

Vancomycin Paste Does Not Reduce the Incidence of Deep Sternal Wound Infection After Cardiac Operations

BACKGROUND Deep sternal wound infection (DSWI) is a devastating complication that increases morbidity and death in cardiac surgical patients. Vancomycin is often administered intravenously for antibiotic prophylaxis in cardiac operations. Many cardiac surgeons also apply vancomycin paste topically to the sternal edges. We examined the effect of vancomycin paste on the incidence of DSWI in patients undergoing elective cardiac operations. METHODS We retrospectively reviewed the medical records of all patients from 2003 to 2015 who underwent coronary artery bypass grafting, valve, or combined coronary artery bypass grafting and valve operations at a single institution. We derived The Society for Thoracic Surgeons (STS) DSWI risk index for each patient and systematically reviewed operative, pharmacy, microbiology, and discharge records to document DSWI in these patients. Multivariate analyses were used to identify predictors of DSWI in this cohort and to quantify the effect of vancomycin paste. RESULTS Of the 14,492 patients whose records we examined, DSWI developed in 136 patients, resulting in an overall incidence of 0.9%. After multivariate analysis, body mass index, New York Heart Association Functional Classification, and the STS DSWI risk index remained statistically significant and associated with DSWI. Although the incidence of DSWI decreased over time, the use of vancomycin paste was not associated with a reduced incidence of DSWI. CONCLUSIONS There was a marked decrease in the incidence of DSWI during the study period, concurrent with institutional implementation of revised STS antibiotic dosing guidelines in 2007 and other strategies. However, the application of vancomycin paste to the sternal edges of patients undergoing cardiac operations was not associated with a reduced risk of DSWI.

Robotic CABG and Hybrid Approaches: The Current Landscape.

Modern treatment of coronary artery disease (CAD) requires a patient-centered approach. With several technological advances, the options for treatment must be carefully weighed and novel approaches tested for safety and efficacy. In this chapter, we outline some of the new approaches available to cardiac surgeons for the treatment of CAD, including off pump coronary artery bypass grafting, minimally invasive as well as hybrid and robotic coronary revascularization. We discuss current evidence and controversies, and highlight the future directions and challenges in the field of surgical coronary revascularization.

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.

Outcomes of repeat mitral valve replacement in patients with prior mitral surgery: A benchmark for transcatheter approaches

Objectives With the emergence of transcatheter mitral valve‐in‐valve/ring replacement for deteriorated bioprostheses or failed repair, comparative clinical benchmarks for surgical repeat mitral valve replacement (re‐MVR) are needed. We present in‐hospital and survival outcomes of a 24‐year experience with re‐MVR. Methods From January 1992 to June 2015, 520 adult patients underwent re‐MVR; 273 had undergone prior mitral valve repair (pMVP) and 247 had undergone prior MVR (pMVR). A benchmark cohort of isolated re‐MVR was defined based on potential eligibility for transcatheter mitral valve‐in‐valve/ring replacement, resulting in 73 pMVPs with previous annuloplasty rings and 74 pMVRs with previous bioprosthetic valves for comparison. Results For the entire cohort, mean age was 64 ± 12 years for pMVP patients and 63 ± 15 years for pMVR patients (P = .281), which was similar for the benchmark cohort. Overall operative mortality was 14 out of 273 (5%) for pMVP versus 23 out of 247 (9%) for pMVR (P = .087). There were 3 operative deaths (4.1%) in both groups of the benchmark cohort (P = 1.0). For the benchmark cohort, median time to reoperation was 9.8 years for pMVP and 9.1 years for pMVR. Cox proportional hazard analysis showed that chronic kidney disease (hazard ratio [HR], 2.47; 95% CI, 1.77‐3.44), endocarditis (HR, 1.49; 95% CI, 1.07‐2.07), pMVR (HR, 1.45; 95% CI, 1.12‐1.89), early reoperation ≤ 1 year (HR, 1.49; 95% CI, 1.02‐2.17), and age (HR, 1.04/y; 95% CI, 1.03‐1.05) were associated with decreased survival after re‐MVR. Conclusions A re‐MVR is a high‐risk operation, but in carefully selected patients such as our benchmark population, it can be performed with acceptable results. Patients undergoing pMVP also have better long‐term survival compared with patients undergoing pMVR. These results will serve as a benchmark for transcatheter mitral valve‐in‐valve/ring replacement.

Should the dilated ascending aorta be repaired at the time of bicuspid aortic valve replacement

OBJECTIVES Bicuspid aortic valve (BAV) is the most common congenital valvular abnormality and frequently presents with accelerated calcific aortic valve disease, requiring aortic valve replacement (AVR) and thoracic aortic aneurysm and dissection. Supporting evidence for Association Guidelines of aortic dimensions for aortic resection is sparse. We sought to determine whether concurrent repair of dilated or aneurysmal aortic disease during AVR in patients with BAV substantially improves morbidity and mortality outcomes. METHODS Mortality and reoperation outcomes of 1301 adults with BAV and dilated aorta undergoing AVR-only surgery were compared to patients undergoing AVR with aortic resection (AVR-AR) using Cox proportional hazards modelling and patient matching. RESULTS Clinically important differences in patient characteristics, aortic valve function and aortic dimensions were identified between cohorts. Event rates were low, with rates of reoperation and death within 1 year of only 1.8% and 5.4%, respectively, and no aortic dissection observed during follow-up. There were no significant differences in reoperation or mortality outcomes between the AVR-only and AVR-AR cohorts. Age, aortic dimension or a combination thereof was not associated with better or worse outcomes after each AVR-AR compared with AVR. CONCLUSIONS We conclude AVR-only and AVR-AR surgery have low morbidity and mortality and have utility over a wide range of age and aortic sizes. Our results do not provide support for the 45-mm aortic dimension recommended in the current guidelines for aortic resection while performing AVR or any other specific dimension.

Severity of tricuspid regurgitation is associated with long-term mortality

Objectives: To determine the association between intraoperative/presurgical grade of tricuspid regurgitation (TR) and mortality, and to determine whether surgical correction of TR correlated with an increased chance of survival compared with patients with uncorrected TR. Methods: The grade of TR assessed by intraoperative transesophageal echocardiography (TEE) before surgical intervention was reviewed for 23,685 cardiac surgery patients between 1990 and 2014. Cox proportional hazard regression models were used to determine association between grade of TR and the primary endpoint of all‐cause mortality. Association between tricuspid valve (TV) surgery and survival was determined with Cox proportional hazard regression models after matching for grade of TR. Results: Kaplan‐Meier survival curves demonstrated a relationship between all grades of TR. Multivariable analysis of the entire cohort demonstrated significantly increased mortality for moderate (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.1‐1.4; P < .0001) and severe TR (HR, 2.02; 95% CI, 1.57‐2.6; P < .0001). Mild TR displayed a trend for mortality (HR, 1.07; 95% CI, 0.99‐1.16; P = .075). After matching for grade of TR and additional confounders, patients who underwent TV surgery had a statistically significant increased likelihood of survival (HR, 0.74; 95% CI, 0.61‐0.91; P = .004). Conclusions: Our study of more than 20,000 patients demonstrates that grade of TR is associated with increased risk of mortality after cardiac surgery. In addition, all patients who underwent TV surgery had a statistically significantly increased likelihood of survival compared with those with the same degree of TR who did not undergo TV surgery.

The risk of reoperative cardiac surgery in radiation-induced valvular disease

Objective: Mediastinal radiation therapy (MRT) increases the risk for adverse outcomes after cardiac surgery and is not incorporated in the Society of Thoracic Surgeons (STS) risk algorithm. We aimed to quantify the surgical risk conferred by MRT in patients undergoing primary and reoperative valvular operations. Methods: A retrospective analysis of 261 consecutive patients with prior MRT who underwent valvular operations between January 2002 and May 2015. Short‐ and long‐term outcomes were compared for STS predicted risk of mortality, surgery type, gender, year of surgery, and age‐matched patients stratified by reoperative status. Results: Mean age was 62.6 ± 12.1 years and 174 (67%) were women. The majority had received MRT for Hodgkin lymphoma (48.2%) and breast cancer (36%). Overall, 214 (82%) were primary and 47 (18%) were reoperative procedures. Reoperation carried a higher operative mortality than primary cases (17% vs 3.7%; P = .003). Compared with the 836 nonradiated matches, operative mortality and observed‐to‐expected STS mortality ratios were higher in primary (3.8% [1.4] vs 0.8% [0.32]; P = .004) and reoperative (17% [3.35] vs 2.3% [0.45]; P = .001) patients with prior MRT. Cox proportional hazard modeling revealed that in patients with previous MRT, primary (hazard ratio, 2.24; 95% confidence interval, 1.73–2.91) and reoperative status (hazard ratio, 3.19; 95% confidence interval, 1.95–5.21) adversely affected long‐term survival compared with nonradiated matches. Conclusions: Surgery for radiation‐induced valvular heart disease has a higher operative mortality than predicted by STS predicted risk of mortality. Reoperations are associated with increased morbidity and mortality compared with primary cases. Careful patient selection is paramount and expanded indications for transcatheter therapies should be considered, especially in reoperative patients.

Surgical pulmonary embolectomy and catheter-directed thrombolysis for treatment of submassive pulmonary embolism

Acute pulmonary embolism (PE) with preserved hemodynamics but right ventricular dysfunction, classified as submassive PE, carries a high risk of mortality. We report the results for patients who did not qualify for medical therapy and required treatment of submassive PE with surgical pulmonary embolectomy and catheter‐directed thrombolysis (CDT).

Novel fast-track recovery protocol for alternative access transcatheter aortic valve replacement: application to non-femoral approaches

OBJECTIVES Although the transfemoral approach for transcatheter aortic valve replacement is the preferred choice, alternative access remains indicated for inadequate iliofemoral vessels. We report the successful implementation of a novel fast-track (FT) protocol for patients undergoing alternative access transcatheter aortic valve replacement compared with conventional controls. METHODS Between September 2014 and January 2017, 31 and 23 patients underwent alternative access transcatheter aortic valve replacement under FT and pre-fast-track (p-FT) protocols, respectively. Comparisons of outcomes (in terms of mortality, complications, readmissions and resource utilization) were made before and after the implantation of the FT protocol in September 2015. RESULTS Overall, mean age was 78.7 years in FT and 79.6 years in p-FT patients (P = 0.71). There were no significant differences in procedural (3.2% vs 13.0%, P = 0.301) or 90-day mortality (3.2% vs 17.4%, P = 0.151) between the FT and p-FT groups, respectively. Compared with p-FT patients, FT patients had significantly shorter intensive care unit stays (12 h vs 27 h, P = 0.006) and a trend towards more discharges within 3 days (41.9% vs 17.4%, P = 0.081). Resource utilization analyses projected a 56% and 17% reduction in the mean intensive care unit time (hours) per 100 patients and the total length of stay (days) per 100 patients, respectively, with respect to the FT approach. CONCLUSIONS This pilot study demonstrates the feasibility and safety of the novel FT protocol for alternative access transcatheter aortic valve replacement, resulting in shorter intensive care unit stays, without increasing procedural complications or readmissions. With the expected increase in transcatheter aortic valve replacement utilization, FT protocols should be integrated with a multidisciplinary heart team approach to enhance patient recovery and optimize resource utilization.