Robin Varghese

Right Ventricular Failure After Cardiac Surgery: Management Strategies

Right ventricular failure after cardiac surgery is a difficult clinical dilemma. We review the physiology of right ventricular failure in addition to current management strategies to address it.

Blood Conservation in Cardiac Surgery: Let's Get Restrictive

Despite increasing evidence suggesting harmful effects of blood transfusions, physician practices are slow to change. A systematic approach is required to successfully minimize the need for red cell transfusions in the perioperative cardiac surgical patient. This involves preoperative, intraoperative, and postoperative strategies to minimize blood loss and maximize blood conservation. In addition it requires physician education regarding the potential deleterious effects of blood and the more recent evidence that restrictive transfusion strategies are safe and possibly beneficial to postoperative surgical outcomes. In this article, we review the data with respect to blood transfusions in cardiac surgery patients as well as management strategies to minimize the need for blood transfusions in the perioperative period.

Predicting early left ventricular dysfunction after mitral valve reconstruction: The effect of atrial fibrillation and pulmonary hypertension

OBJECTIVEnThe preoperative ejection fraction (EF) and left ventricular (LV) end-systolic dimension are known predictors of postoperative LV dysfunction after mitral valve repair. We investigated the effect of a preoperative history of atrial fibrillation and moderate pulmonary hypertension (defined as pulmonary artery systolic pressure >50 mm Hg) on early postoperative LV dysfunction.nnnMETHODSnFrom 2003 to 2010, 632 patients who had undergone successful mitral valve repair surgery for degenerative disease were included in the present study. The preoperative and postoperative echocardiographic data and postoperative outcomes were collected retrospectively. We analyzed the demographic, hemodynamic, and echocardiographic parameters to assess the predictors of early postoperative LV dysfunction, defined as an LVEF <50%.nnnRESULTSnThe mean age of the cohort was 57 ± 13 years. All patients had less than mild mitral regurgitation onxa0postoperative echocardiography. After mitral valve repair, a significant decrease in the LVEF (60% ± 8% to 54% ± 9%), LV end-systolic diameter (36 ± 7 mm to 33 ± 7 mm), and LV end-diastolic dimension (56xa0± 8 mm to 48 ± 7 mm) was observed at early postoperative echocardiography (Pxa0<xa0.001). On multivariate regression analysis, preoperative atrial fibrillation, pulmonary hypertension, and LV end-systolic dimension were independent predictors of the postoperative LVEF (Pxa0=xa0.035 and Pxa0<xa0.001, respectively). Preoperative atrial fibrillation (odds ratio, 1.97; 95% confidence interval, 1.28-3.02; Pxa0=xa0.002) and pulmonary artery systolic pressure >50 mm Hg (odds ratio, 1.82; 95% confidence interval, 1.11-2.97; Pxa0=xa0.017) increased the risk of postoperative LV dysfunction by almost twofold.nnnCONCLUSIONSnIn addition to the established predictors of postoperative LV dysfunction, the presence of preoperative pulmonary hypertension and a history of atrial fibrillation in patients undergoing mitral valve repair surgery increased the risk of early postoperative LV dysfunction by almost twofold.

Re-repair of the mitral valve as a primary strategy for early and late failures of mitral valve repair

OBJECTIVESnWith the expanding uptake of mitral valve repair as the primary therapy for mitral valve regurgitation, an increasing cohort of patients are presenting with failures following valve repair. These patients have traditionally been treated by mitral valve replacement. We have adopted an aggressive strategy of valve re-repair for failures of mitral valve repair and present our mid-term results.nnnMETHODSnFifty-three consecutive adults underwent reoperation by a single surgical team for failed non-rheumatic mitral valve repair. Primary valve repair had been done for degenerative (n=38), congenital (n=6), infective (n=3), functional (n=1) or unknown (n=5) mitral disease. The reoperative mitral procedure occurred at a median interval of 3 (interquartile range 0.9-6.5) years from the primary mitral valve repair. Valve re-repair was attempted if the anterior leaflet was sufficiently pliable, and lesions causing recurrence were identifiable and deemed treatable. Standard repair techniques were employed in re-repair procedures.nnnRESULTSnValve analysis showed that the mode of failure was progression of original disease in 19 (36%), technical failure in 20 (38%) and new disease in 14 (26%) patients. Valve re-repair was successfully accomplished in 45 (85%) patients. Re-repair was most frequent when the prior aetiology was degenerative (34 of 38, 90%) as opposed to non-degenerative (11 of 15, 73%). There were no hospital deaths. Four-year patient survival was 97%. Freedoms from moderate mitral regurgitation were 100, 95, 88 and 80% at discharge and at 1, 3, and 4 years, respectively. There were no reoperations in the follow-up period.nnnCONCLUSIONSnRe-repair of the mitral valve is feasible in most of the cases of failed mitral valve repair of non-rheumatic aetiology and has acceptable mid-term outcomes. The relatively high prevalence of technical failures as the mechanism of failure of the primary mitral valve repair suggests the need for ongoing surgical education and continuing development and refinement of repair techniques.

Right coronary artery injury after tricuspid valve repair.

Tricuspid valve repair can result in right coronary artery injury secondary to valve annuloplasty. We report a case in which a patient developed right coronary artery occlusion because of tricuspid valve repair and review management options. An 83-yearold gentleman with a past medical history of mitral valve prolapse developed Class III symptoms of congestive heart failure in addition to atrial fibrillation and pulmonary hypertension. Transthoracic echocardiogram revealed preserved ventricular function and severe mitral regurgitation secondary to annular dilation with minimally restricted leaflet motion. In addition, moderate tricuspid regurgitation was evident secondary to annular dilation. Preoperative cardiac angiography revealed nonobstructive coronary artery disease and a right dominant system. The patient underwent a mitral valve repair, tricuspid valve repair, and cryomaze procedure. Intraoperatively the mitral valve was exposed via Sondergaard’s groove. A left and right atrial cryomaze ablation was performed. Mitral valve analysis revealed normal leaflet motion, with some mild restriction of P2 and P3 chords. These chords were divided, and an indentation between P2 and P3 was closed. The repair was completed with implantation of a true-sized 26-mm Physio annuloplasty ring (Edwards Life Sciences, Irvine, CA). After this the tricuspid valve was exposed. Annular sutures were placed from the anteroseptal to just past the posteroseptal commissures and the repair was completed by the use of a 25-mm ATS flexible annuloplasty band (ATS Medical, Minneapolis, MN). The right atrium was closed, the heart evacuated of air, and the cross clamp removed. There were no apparent ST changes noted initially. The right ventricular and left ventricular function appeared normal except for mild inferior wall hypokinesia.

Quality of life and survival of septuagenarians and octogenarians after repair of descending and thoracoabdominal aortic aneurysms

OBJECTIVEnWe assessed quality of life and survival in elderly patients after complex aortic operations to aid in surgical decision making.nnnMETHODSnA retrospective review was performed of 93 patients who underwent descending thoracic aneurysm or thoracoabdominal aortic aneurysm (TAAA) repair from 2002 to 2008. A Cox model was used for survival analysis. The SF-36 Item Health Survey was administered to assess postoperative quality of life in 39 patients and was compared with age- and gender-matched normal scores.nnnRESULTSnThe mean age at operation was 75 ± 4.1 years; 51% of patients were male. In-hospital mortality was 15%. One-year survival was 69%, and 5-year survival was 45%. Only acute respiratory distress syndrome was a predictor of in-hospital mortality (hazard ratio = 3.75; P < .01) and 1-year mortality (hazard ratio = 4.61; P < .001). After 1 year, patients enjoyed longevity equivalent to that of a normal age- and gender-matched population (standardized mortality ratio = 1.06; P = .81). Being male is a predictor of long-term survival (hazard ratio = 0.18; P < .05). For women, extremely low and high body mass indexes (quadratic term = 0.020; P < .05) with an inflection point of body mass index of 28 is a risk factor of long-term survival. Quality of life scores were similar to those of the general population except for lower vitality scores, (s-score = -0.67, 95% CI, -1.09 to -0.26).nnnCONCLUSIONSnTAAA repair in this selected older surgical population yields acceptable survival beyond the first year. Among 1-year survivors, quality of life is similar to that of an age- and gender-matched population.

Rationale and initial experience with the Tri-Ad Adams tricuspid annuloplasty ring

Controversy exists regarding the indication and method of repair of functional tricuspid regurgitation (TR) in patients undergoing mitral valve surgery. Whereas the American College of Cardiology/American Heart Association guidelines recommend tricuspid repair in the setting of severe TR, tricuspid repair is advised for less than severe TR in the setting of annular dilation or pulmonary hypertension. Although multiple repair strategies exist, the use of a ring annuloplasty (semirigid remodeling rings vs flexible bands) is the preferred method of therapy to avoid short- and long-term recurrence of TR. The new Tri-Ad Adams annuloplasty ring combines elements of semirigid and flexible bands that will not only allow for annular remodeling in the region of the right ventricular free wall but also potentially reduce injury to the conduction system with its flexible and open ends. In this article, we discuss the rational for an aggressive approach to functional tricuspid regurgitation, and show our initial clinical experience with the Tri-Ad Adams annuloplasty ring.

Current approach to diagnosis and treatment of delirium after cardiac surgery

Delirium after cardiac surgery remains a common occurrence that results in significant short- and long-term morbidity and mortality. It continues to be underdiagnosed given its complex presentation and multifactorial etiology; however, its prevalence is increasing given the aging cardiac surgical population. This review highlights the perioperative risk factors, tools to assist in diagnosing delirium, and current pharmacological and nonpharmacological therapy options.

Blood Conservation in Cardiac Surgery: In Need of a Transfusion Revolution.

Blood transfusion is the most common procedure in cardiac surgery. Increasing evidence exists that excess transfusions are harmful to patients. Transfusion reactions and complications, including infection, immune modulation, and lung injury, are known complications but underreported; hence, their significance is often disregarded. Furthermore, a number of randomized trials have shown that a restrictive transfusion strategy is equal to if not better than a liberal transfusion strategy. Despite the evidence for the use of restrictive transfusion triggers, its dissemination in the cardiac surgical community has met with resistance. In this review, we outline the risks of transfusion, compare restrictive and liberal transfusion strategies in cardiac surgery, and finally outline perioperative interventions to minimize transfusion in the cardiac surgical patient.

Assessment of Surgical Septal Myectomy by Real-Time 3-Dimensional Transesophageal Echocardiography

The left ventricular outflow tract (LVOT) is a 3-dimensional structure. Consequently, 2-dimensional transesophageal echocardiography (2D TEE) will never be able to truly assess this structure’s dimensions during the cardiac cycle. While Doppler technology can provide the imager with indirect information regarding the adequacy of septal resection (reduction in pressure gradient, loss of turbulent flow distal to the obstruction), only 3-dimensional imaging is capable of directly quantifying the adequacy of resection. The authors report the use of realtime 3-dimensional TEE (RT 3D TEE) imaging to assess the adequacy of surgical septal myectomy.