Michelle Capdeville

The risk of coronary artery surgery in women: A matched comparison using preoperative severity of illness scoring

OBJECTIVE To evaluate the effect of gender on outcomes of coronary artery bypass surgery using a weighted preoperative severity of illness scoring system. DESIGN Retrospective database review. SETTING Tertiary care teaching hospital. PARTICIPANTS The patient population consisted of 2,800 consecutive coronary artery bypass graft (CABG) patients (658 women, 2,142 men), with or without concurrent procedures, operated on between January 1, 1993 and March 31, 1994. MEASUREMENTS AND MAIN RESULTS Patients were stratified for severity of illness using a 13-element scoring system. The distribution of severity of illness scores and severity of illness-stratified morbidity, hospital mortality, and intensive care unit (ICU) length of stay were compared by chi-square and Fischers exact test where appropriate. Median duration of intubation and median duration of ICU length of stay were examined by the median test. Female versus male unadjusted mortality (4.9% v 3.0%), total morbidity (15.0% v 9.2%), and average initial ICU length of stay (92.62% v 60.56 hours) were statistically different. Female patients also had significantly more of the following postoperative morbidities: central nervous system complications (focal neurologic deficits, patients > or = 65 years 3.20% v 1.54%; global neurologic deficits, patients > or = 65 years 2.75% v 1.25%), duration of perioperative ventilation that includes the intubation time in the operating room until extubation in the ICU (average = 77.36 hours v 49.20 hours; median = 21.87 v 20.26 hours), and average initial ICU length of stay (average = 92.62 hours v 60.56 hours; median = 42.33 hours v 27.91 hours). However, distribution of severity scores was also different. Women had significantly more preoperative risk factors (p < 0.05): age 65 to 74 years (45.1% v 36.6%), age > or = 75 years (21.3% v 11.9%), chronic obstructive pulmonary disease (10.8% v 6.4%), hematocrit less than 34% (21.9% v 5.5%), diabetes (34.8% v 21.8%), weight less than 65 kg (37.4% v 6.2%), and operative mitral valve insufficiency (9.6% v 6.0%). Stratified by severity, no statistically significant gender differences were found for mortality, morbidity, or ICU length of stay. CONCLUSIONS Gender does not appear to be an independent risk factor for perioperative morbidity, mortality, or excessive ICU length of stay when patients are stratified by preoperative risk in this severity of illness scoring system.

Practical use of a bronchial blocker in combination with a double-lumen endotracheal tube

1 ung separation is an essential component of many thoracic and mediastinal procedures. This is achieved most commonly with the use of a double-lumen endotracheal tube (DLT) (1,2), a singlelumen tube with a bronchial blocker, endobronchial intubation with a long single-lumen tube, or the UniventTM tube (Fuji Systems Corporation, Tokyo, Japan), which has an incorporated movable endobronchial blocker (3-5). A DLT allows relatively easy collapse of the nonventilated lung and the ability to suction each lung independently. A main disadvantage is the limited size range (i.e., 28, 35,37, 39, and 41F). A vascular embolectomy catheter may be used as a bronchial blocker when placed either outside or within the lumen of a single-lumen tube. Placement down the left mainstem bronchus can be challenging because of its greater takeoff angle and smaller diameter; complete isolation of the right lung can be impossible in some situations, depending on the takeoff of the right upper lobe bronchus. Absolute indications for lung separation include prevention of spillage and contamination of a healthy lung with blood or purulent material; unilateral bronchoalveolar lavage; and bronchopleural fistula. Relative indications include facilitation of surgical exposure at thoracotomy or during certain cardiac operations (e.g., transmyocardial revascularization, minimally invasive direct coronary artery bypass). We describe a patient who presented for thoracotomy and whose left mainstem bronchus was too small to accept the bronchial lumen of a 35F left-sided DLT.

Advances and Future Directions for Mechanical Circulatory Support

Although cardiac transplant remains the gold standard for the treatment of end-stage heart failure, limited donor organ availability and growing numbers of eligible recipients have increased the demand for alternative therapies. Limitations of first-generation left ventricular assist devices for long-term support of patients with end-stage disease have led to the development of newer second-generation and third-generation pumps, which are smaller, have fewer moving parts, and have shown improved durability, allowing for extended support. The HeartMate II (second generation) and HeartWare (third generation) are 2 devices that have shown great promise as potential alternatives to transplantation in select patients.

Parachute-like Asymmetric Mitral Valve Associated With Mitral Valve Cleft and Atrial Septal Defect in an Adult

e M p a p o APARACHUTE MITRAL VALVE (PMV) is a rare congenital cardiac defect characterized by focalized attachment of he chordae tendineae of both leaflets to a single papillary muscle. n contrast to true PMV, a parachute-like asymmetric mitral alve (PLAMV) has 2 separate papillary muscles, one being ore pronounced with all chordae inserted into this domiant muscle. Most frequently, the involved dominant muscle s a posteromedial papillary muscle. The present case report escribes an occurrence of PLAMV coincident with mitral alve cleft (MVC) and an atrial septal defect (ASD) in an dult. To the best of the authors’ knowledge, the occurrence f PLAMV in association with MVC and ASD has not been escribed in the literature in an adult patient.

An Unusual Cause of Left Ventricular Outflow Tract Obstruction

YPERTROPHIC CARDIOMOPATHY (HCM) is a complex condition with an extensive phenotypic expression and a broad clinical spectrum. Mutations in the sarcomeric proteins lead to abnormal hypertrophy, especially of the interventricular septum. 1 The prevalence of this condition in the adult population is approximately 0.2%, and it is considered the most common genetic cardiac disease. 2 The most common phenotype is characterized by dynamic left ventricular outflow tract (LVOT) obstruction resulting from basal septal hypertrophy and systolic anterior motion (SAM) of the anterior mitral valve leaflet. The rapid ejection of blood across a narrowed outflow tract results in a Venturi or drag effect, which, in turn, draws the mitral leaflet and chordae toward the interventricular septum. 3 Interestingly, similar degrees of basal hypertrophy can have different degrees of LVOT obstruction and symptoms. The clinical diagnosis is reliably confirmed with 2-dimensional echocardiography and Doppler measurement of outflow tract gradients. The authors present an unusual cause of LVOT obstruction in a patient who carried the diagnosis of HCM and who had undergone prior operations for the management of subaortic stenosis.

CASE 5—2016Complex Congenital Cardiac Surgery in an Adult Patient With Hereditary Spherocytosis: Avoidance of Massive Hemolysis Associated With Extracorporeal Circulation in the Presence of Red Blood Cell Fragility

XTRACORPOREAL CIRCULATORY support among patients with genetic disorders producing erythrocyte fragility requires specific considerations involving decreasing shear stresses on red blood cells (RBCs) and vigilant intraoperative and postoperative monitoring for catastrophic hemolytic anemia. Hereditary spherocytosis (HS) is an autosomal dominant hemolytic anemia characterized by spheroid-shaped erythrocytes with increased osmolality and rigidity. Clinical presentation of HS varies depending on genetic penetrance. Decreased flexibility within the RBC membrane limits deformation and increases the possibility of hemolysis. Specifically, the mechanical stress of cardiopulmonary bypass (CPB) on HS erythrocytes presents a challenge during cardiac surgery. Although previous case reports of successful use of CPB during cardiac surgery in HS patients have been published, 1-13 significant perioperative hemolysis also has been reported. 6 The authors report the successful use of CPB in an adult HS patient undergoing multiple complex cardiac congenital repairs and review perioperative concerns and management.

Turbulence in the left ventricular outflow tract caused by an eccentric mitral inflow jet masquerades as aortic regurgitation.

January 2014 • Volume 118 • Number 1 A 48-year-old woman with a previous mechanical bileaflet mitral valve replacement was diagnosed with severe mitral stenosis and moderately severe aortic regurgitation by transthoracic echocardiography. She was referred to our institution for surgical replacement of her aortic and mitral valves. Our IRB waived the requirement for patient consent for this report. In the operating room after anesthetic induction, a transesophageal echocardiographic (TEE) midesophageal 4-chamber view confirmed an immobile mechanical mitral valve leaflet causing severe mitral stenosis (Video 1, see Supplemental Digital Content 1, http://links.lww.com/ AA/A679). Mean transmitral pressure gradient measured with continuous wave Doppler was 19 mm Hg with a heart rate of 55 bpm. A midesophageal long-axis view with color flow Doppler demonstrated severe turbulence in the left ventricular outflow tract (LVOT) during diastole, suggesting severe aortic regurgitation (Fig. 1; Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A680). A midesophageal aortic valve short-axis view (partially cut through the LVOT) suggested aortic regurgitation (Video 3, see Supplemental Digital Content 3, http://links.lww. com/AA/A681). Significant shadowing from the mechanical mitral valve created difficulty in determining whether the jet resulted from aortic regurgitation or mitral inflow. Thus, other echocardiographic measures to differentiate the etiology of the diastolic LVOT turbulence were performed. A deep transgastric long-axis view which allowed imaging of the LVOT without shadowing from the prosthetic mitral valve demonstrated absence of turbulence proximal to the aortic valve, suggesting that LVOT turbulence did not originate from the aortic valve. Furthermore, spectral Doppler demonstrated LVOT flow, which peaked at less than 2.0 m/s and followed mitral valve opening (rather than aortic valve closing), consistent with mitral inflow (Fig. 2). Additional echocardiographic evidence inconsistent with severe aortic regurgitation was documented, including aortic valve leaflets without significant abnormalities, a normal-appearing aortic root, and absence of flow reversal in the descending aorta. These findings suggested that diastolic LVOT turbulence was related to an eccentric mitral inflow jet, rather than aortic regurgitation. The patient underwent mitral valve replacement with a 27-mm St. Jude bileaflet mechanical mitral valve (St. Jude Medical, St. Paul, MN). TEE performed after separation from cardiopulmonary bypass demonstrated a well-seated mitral valve and a competent aortic valve.

Gender Disparities in Cardiovascular Fellowship Training Among Three Specialties from 2007-2017

Despite women accounting for nearly half of all U.S. medical school graduates, this balanced representation is lacking in the cardiovascular specialties. To explore this question further, gender-based trends in the selection of cardiovascular subspecialty fellowship training were investigated among three core specialties: anesthesiology, medicine, and surgery. Using enrollment and workforce data from the Accreditation Council for Graduate Medical Education (ACGME), the Association of American Medical Colleges (AAMC), and the Journal of the American Medical Association Annual Report on Graduate Medical Education, trends in cardiovascular fellowship selection among women were examined over a 10-year period (2007-2017). An attempt was also made to better understand barriers that might contribute to any discrepancies, as well as factors that might influence womens choices of cardiovascular specialties over other fields.

Redo cardiac surgery in a patient with severe kyphoscoliosis and pectus carinatum: A technical challenge

correct expansion of the aortic valve prosthesis. For this reason, some authors recommend that the implantation be performed as high as possible. This intention might lead to malpositioning too high in the left ventricular outflow tract, however, potentially causing aortic regurgitation or, even worse, occlusion of the coronary arteries. It is therefore necessary for the user to find a position that respects these aspects. The new Engager aortic valve prosthesis is designed to capture the native leaflets of the origin aortic valve with its control arms by placing it as close to the native aortic annulus as possible. We could prove that the resulting distance ensures not only a correct expansion of the aortic valve prosthesis but also a proper function of a previously implanted mitral valve prosthesis. This perfect positioning with respect to the localization of the two valve prostheses and the coronary arteries can be achieved just by the