K.L. Losenno

Defining the Efficacy of Aortic Root Enlargement Procedures: A Comparative Analysis of Surgical Techniques

BACKGROUNDnAortic root enlargement (ARE) procedures are believed to allow implantation of larger valve prostheses; however, little evidence exists to support the specific efficacy of various techniques.nnnMETHODSnUsing a cadaveric model, 20 adult (72.4 ± 15.3 years) hearts were stratified into 4 groups based on annular diameter: <20 mm, 20-22 mm, 22-24 mm, and >24 mm. Each heart underwent an aortic valve replacement following a Nicks, Manougian, aortoventriculoplasty and modified Bentall procedure, with appropriate reversals between procedures.nnnRESULTSnAll 4 groups experienced similar increases in annular diameter (P = 0.43) and prosthesis size implanted (P = 0.51) with each enlargement technique. The Nicks, Manougian, modified Bentall and aortoventriculoplasty procedures enlarged the annulus by 0.43 ± 0.45 mm, 3.63 ± 0.95 mm, 0.78 ± 0.65 mm, and 6.08 ± 1.19 mm, respectively (P < 0.001). No significant change in prosthesis size was observed after the Nicks procedure (P = not significant). Increases of 1.3 ± 0.5, 1.3 ± 0.5, and 2.7 ± 0.6 prosthesis sizes were achieved with the Manougian, modified Bentall and aortoventriculoplasty techniques respectively (P < 0.001).nnnCONCLUSIONSnARE procedures appear equally efficacious in both small and larger aortic roots. Although all 4 ARE techniques increased the annular diameter, only the Manougian, modified Bentall and aortoventriculoplasty procedures allowed for the implantation of a larger prosthetic valve. The Nicks procedure, which is likely the most commonly performed ARE, does not allow for the implantation of a larger prosthesis. Surgeon preference and patient factors may help in selecting the most appropriate ARE technique, as the modified Bentall and Manougian procedures achieved similar increases in valve size.

Complex tricuspid valve repair for infective endocarditis: leaflet augmentation, chordae and annular reconstruction

Surgical treatment of tricuspid valve (TV) endocarditis remains a challenge because of extensive valve destruction, high risk of reinfection, poor outcomes with valve replacement and complex patient compliance issues. Reconstruction of the TV is certainly favoured over replacement; however, diffuse, multifocal vegetations and complete debridement often leave insufficient building materials necessary for repair. We describe our surgical reconstructive technique that relies upon extensive autologous pericardial patch augmentation of the destroyed TV leaflets to establish leaflet coaptation, supplemented with expanded polytetrafluoroethylene neo-chordae and annular reconstruction. We report our outcomes in a series of patients with grossly infected TVs with more than 50% of valvular destruction.

Bicuspid aortic valve disease

Bicuspid aortic valves are present in 1%–2% of the population, with men being 3 times more commonly affected than women. This disease is more than just anatomic variation and may be associated with other heart and aorta abnormalities as a result of molecular and connective tissue derangements.[1][

Whole body perfusion strategy for aortic arch repair under moderate hypothermia

Introduction: Aortic arch reconstruction under moderate hypothermia is commonly performed with antegrade cerebral perfusion (ACP) for brain protection; however, hypothermia alone is often solely relied upon for visceral and lower body protection. We investigated whether the addition of simultaneous lower body perfusion to ACP (whole body perfusion - WBP) may ameliorate the metabolic derangements of moderate hypothermic circulatory arrest (MHCA). Methods: Between 2008 and 2014, 106 consecutive patients underwent elective or emergent aortic arch surgery with MHCA, with either ACP only (44 patients, 66±12 years, 30% female) or WBP (62 patients, 61±15 years, 31% female). Primary outcomes included 30-day/in-hospital mortality, intensive care unit (ICU) and hospital lengths of stay (LOS) and specific parameters of metabolic recovery. Results: There were no significant differences between the groups in 30-day/in-hospital mortality (ACP: 3 (6.8%), WBP: 2 (3.2%); p=0.65), stroke (ACP: 1 (2.3%), WBP: 1 (1.6%); p=1.0) or renal failure (ACP: 2 (4.5%), WBP: 1 (1.5%); p=0.57). In the WBP group, we identified a significant reduction in lactate level at ICU admission (ACP 5.5 vs. WBP 3.5 mmol/L; p=0.002), time to lactate normalization (p=0.014) and median ICU length-of-stay (ACP 3 vs. WBP 1 days; p=0.049). There was no difference in post-operative creatinine (ACP: 104, WBP: 107 μmol/L; p=0.66). After multivariable regression adjustment, perfusion strategy no longer remained an independent predictor of ICU discharge time (p=0.09), however, cardiopulmonary bypass time (p=0.02), age (p=0.012) and emergent surgery (p=0.02) were. Conclusions: A WBP strategy during aortic arch reconstruction with MHCA may be associated with more rapid normalization of metabolic parameters and reduced ICU length of stay compared to using ACP alone. Further evaluation with a randomized trial is warranted.

Expanding Eligibility for the Ross Procedure: A Reasonable Proposition?

BACKGROUNDnAlthough the Ross procedure offers potential benefits in young adults, technical complexity represents a significant limitation. Therefore, the safety of expanding its use in more complex settings is uncertain. The aim of this study was to compare early outcomes of standard isolated Ross procedures vs expanding elgibility to higher-risk clinical settings.nnnMETHODSnFrom 2011 to 2016, 261 patients (46 ± 12 years) underwent Ross procedures in 2 centres. Patients were divided into 2 groups: standard Ross (nxa0= 166) and expanded eligibility Ross (nxa0=xa095). Inclusion criteria for the expanded eligibility group were previous cardiac surgery, acute aortic valve endocarditis, severely impaired left ventricular (LV) function and patients undergoing concomitant procedures. All data were prospectively collected and are 100% complete.nnnRESULTSnHospital mortality was 0% in the standard group (0/166) vsxa02% in the expanded eligibility group (2/95) (Pxa0= 0.13). Sixteen patients (10%) developed acute renal injury in the standard group vs 13 (14%) patients in the expanded eligibility group (Pxa0= 0.31). There were no postoperative myocardial infarctions, no neurological events, and no infectious complications. Median intensive care unit (ICU) stay in the standard group was 2 vs 3 days in the expanded eligibility group (Pxa0= 0.004), whereas median hospital stay was 6 vs 7 days, respectively (range: 3-19 days) (P < 0.001).nnnCONCLUSIONnAside from longer ICU and hospital lengths of stay after the Ross procedure in higher-risk clinical scenarios, perioperative mortality and morbidity is similar to standard Ross procedures. Expanding the use of the Ross operation in young adults is a safe alternative in centres of expertise.

IMPACT OF A WHOLE BODY PERFUSION STRATEGY DURING CIRCULATORY ARREST FOR AORTIC ARCH RECONSTRUCTIVE SURGERY

BACKGROUND: Wide variation across hospitals in choice of revascularization treatment has been observed and outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) are increasingly being examined. Our cardiology evaluation unit was mandated by the Quebec Ministry of Health to evaluate the practice of multivessel revascularization and its outcomes across Quebec’s 8 tertiary cardiac hospitals offering both PCI and CABG. METHODS: We identified all patients who underwent either multivessel ( 2 myocardial territories) PCI or CABG in 2010-12. A maximum of 300 patients treated with CABG and 300 patients treated with PCI (excluding primary PCI) per hospital were randomly selected for chart review. Factors associated with choice of treatment (PCI vs CABG) were identified using multivariate regression analysis. RESULTS: The study cohort included 2016 PCI patients and 2274 CABG patients. At the provincial level, factors associated with treatment by PCI included older age ( 75 years; OR1⁄41.7; 95% CI: 1.4-2.1), female sex (OR1⁄41.8; 95% CI: 1.4-2.2) and previous PCI (OR1⁄42.1; 95% CI: 1.7-2.5). Relative to patients with elective status, those with urgent/ emergent status were more likely to have undergone PCI than CABG (OR1⁄42.0; 95% CI: 1.6-2.4). Factors associated with CABG were arterial hypertension (OR1⁄41.7; 95% CI: 1.42.1), heart failure (OR1⁄43.3; 95% CI: 2.5-4.3) and 3-vessel disease (OR1⁄416.7; 95% CI: 13.9-20.0). Across the 8 hospitals, the proportion of female patients aged 75 ranged from 31 to 54% for both PCI and CABG. The proportion of elective procedures across hospitals ranged from 17% to 35% for PCI and from 26% to 48% for CABG. The proportion of patients treated with PCI for 3-vessel disease varied by hospital from 5% to 19% while it ranged from 60% to 78% for CABG. Diabetes was not associated with choice of treatment. Across the 8 hospitals, prevalence of diabetes varied from 23% to 36% among PCI patients and from 31% to 40% among CABG patients. One in 9 multivessel PCI patients underwent unprotected left main intervention (range 2.5% to 15.2% across hospitals). CONCLUSION: Although CABG was the predominant treatment for 3-vessel disease, use of PCI in these patients was not uncommon and varied widely by hospital. Presence of diabetes did not impact treatment choice. PCI was used more frequently than CABG for non-elective cases. Patient characteristics varied more by hospital for PCI than for CABG. These results point to the importance of appropriate risk adjustment when comparing outcomes by choice of treatment and by hospital.