William Y. Shi

Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival.

OBJECTIVES We sought to evaluate our experience with total arterial revascularization and compare it with the traditional approach of a single internal thoracic artery supplemented by saphenous veins. METHODS From 1995 to 2010, 6059 patients with triple-vessel coronary artery disease underwent primary isolated coronary artery bypass grafting at 8 centers. A study cohort of 3774 patients was formed, with 2988 (79%) undergoing total arterial revascularization and 786 (21%) receiving only saphenous veins to supplement a single in situ internal thoracic artery. In the total arterial revascularization group, bilateral internal thoracic arteries were used in 1079 patients (36%) and at least 1 radial artery was used in 2916 patients (97%). Propensity score matching was used for risk adjustment. RESULTS Patients undergoing total arterial revascularization were younger (65.0±10.4 years vs 71.3±7.9 years, P<.001) and less likely to have diabetes, cerebrovascular disease, recent myocardial infarction, and severe left ventricular impairment. At 15 years, patients who underwent total arterial revascularization experienced superior unadjusted survival (62%±1.1% vs 35%±1.9%, P<.001). Multivariable Cox regression in the entire study cohort showed the total arterial group had improved survival with a hazard ratio of 0.79 (95% confidence interval, 0.70-0.90; P<.001). After propensity score matching yielded 384 patient pairs, patients who underwent total arterial revascularization showed improved survival at 15 years than patients who underwent single arterial revascularization (54%±3.3% vs 41%±3.0%, P=.0004). CONCLUSIONS This large multicenter study suggests that a strategy of total arterial revascularization is associated with improved long-term survival compared with the use of only a single arterial and saphenous vein grafts. Total arterial revascularization should be encouraged in patients with a reasonable life expectancy.

Minimally Invasive Versus Sternotomy Approach for Mitral Valve Surgery in Patients Greater Than 70 Years Old: A Propensity-Matched Comparison

BACKGROUND The goal of this study was to compare the outcome after mitral valve surgery through either standard sternotomy or right lateral minithoracotomy in elderly patients with higher perioperative risk. METHODS All 1,027 elderly patients (>70 years) who received isolated mitral valve surgery (± tricuspid valve repair) between August 1999 and July 2009 were analyzed for outcome differences due to surgical approach using propensity score matching. The etiology of mitral valve disease was degenerative (83%), endocarditis (6%), rheumatic (10%), and acute ischemic (<1%). Isolated stenosis was rare (3%); most patients had mitral valve regurgitation (72%) or combined mitral valve disease (25%). RESULTS The minimally invasive approach led to longer duration of surgery (186 ± 61 vs 169 ± 59 minutes, p = 0.01), cardiopulmonary bypass time (142 ± 54 vs 102 ± 45 minutes, p = 0.0001), and cross-clamp time (74 ± 44 vs 64 ± 28 minutes, p = 0.015). There were no differences between the matched groups in 30-day mortality (7.7% vs 6.3%, p = 0.82), combined major adverse cardiac and cerebrovascular events (11.2% vs 12.6%, p = 0.86), or other postoperative outcome. Only the number of postoperative arrhythmias and pacemaker implants was higher in the sternotomy group (65.7% vs 50.3%, p = 0.023 and 18.9% vs 10.5%, p = 0.059). Long-term survival was 66% ± 5.6% vs 56 ± 5.5% at 5 years and 35% ± 12% vs 40% ± 7.9% at 8 years, and did not show significant differences. CONCLUSIONS Minimally invasive mitral valve surgery through a right lateral minithoracotomy is at least as good and safe as the standard sternotomy approach in elderly patients.

Custodiol versus blood cardioplegia in complex cardiac operations: an Australian experience

OBJECTIVES A single or dual-dose strategy for myocardial protection is attractive in long operations, in avoiding the need to interrupt the procedure to re-administer cardioplegia. We hypothesized that a single administration of Bretschneider histidine-tryptophan-ketoglutarate (HTK) crystalloid solution (Custodiol) offers myocardial protection comparable with repeated tepid blood cardioplegia. METHODS We reviewed a prospectively compiled single-centre database containing all adult cardiac procedures performed from January 2005 to January 2011. Preoperative demographic and investigative data, operative variables and postoperative (30-day) mortality and morbidity were compared between the Custodiol and blood cardioplegia groups. The study primary endpoints were 30-day mortality, return to the operating theatre, myocardial infarction, stroke, postoperative requirement for an intra-aortic balloon pump, new renal failure, prolonged ventilation and re-admission to hospital within 30 days. Propensity score matching was performed to correct for any bias that may have been associated with the usage of Custodiol. RESULTS A total of 1900 cardiac surgical procedures were identified of which 126 (7%) utilized Custodiol and 1774 (93%) used blood cardioplegia as the primary cardioplegic agent. After propensity-score matching, we were able to match 71 Custodiol cases one-to-one to those receiving blood cardioplegia. There were no statistically significant differences noted for any of the endpoints studied after propensity-score matching. In particular, the proportion of mortality (blood cardioplegia: 1 vs Custodiol 4%, P = 0.63) any mortality/morbidity (blood cardioplegia: 35 vs Custodiol: 39% P = 0.46) was similar between the groups. CONCLUSIONS The use of Custodiol is convenient, simple and at least as safe as tepid blood cardioplegia for myocardial protection in complex cardiac operations. A randomized prospective comparison of myocardial protection strategies is warranted.

The Fontan epidemic: Population projections from the Australia and New Zealand Fontan Registry

BACKGROUND The number and age demographic of the future Fontan population is unknown. METHODS Population projections were calculated probabilistically using microsimulation. Mortality hazard rates for each Fontan recipient were calculated from survivorship of 1353 Fontan recipients in the Australia and New Zealand Fontan Registry, based on Fontan type, age at Fontan, gender and morphology. Projected rates of new Fontan procedures were generated from historical rates of Fontan procedures per population births. RESULTS At the end of 2014, the living Fontan population of Australia and New Zealand was 1265 people from an Australian and New Zealand regional population of 28 million (4.5 per 100,000 population). Of those, 165 (13%) received an atrio-pulmonary (AP) procedure, 262 (21%) a lateral tunnel (LT) procedure and 838 (66%) an extra-cardiac conduit (ECC) procedure. This population is expected to grow to 1917 (95% CI: 1846: 1986) by 2025 (5.8 per 100,000 population), with 149 (8%) AP procedures, 254 (13%) LT procedures, and 1514 (79%) ECC procedures. By 2045, the living Fontan population is expected to reach 2986 (95% CI: 2877: 3085; 7.2 per 100,000 population). The average age of the Fontan population is expected to increase from 18years in 2014 to 23years (95% CI: 22-23) by 2025, and 31years (95% CI: 30-31) by 2045. CONCLUSION The Australian and New Zealand population of patients alive after a Fontan procedure will double over the next 20years increasing the demand for heart-failure services and cardiac transplantation. Greater consideration for the needs of this mostly adult Fontan population will be necessary.

Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies

OBJECTIVE Total arterial revascularization (TAR) with internal thoracic arteries (ITAs) and radial arteries (RA) is associated with greater long-term survival compared with the use of a single internal thoracic artery supplemented by veins. The optimal conduit choice and configuration in achieving TAR remains controversial, with uncertainty regarding the individual prognostic impact of ITAs and RAs. As such, among patients solely undergoing TAR, we compared long-term survival between patients receiving single thoracic arteries and those receiving bilateral ITAs. METHODS From 1995 to 2010, 2821 patients with 3-vessel coronary artery disease at 8 centers underwent primary isolated coronary artery bypass with TAR using ITAs and RAs. Bilateral ITAs were used in 912 patients. In 380 cases, bilateral in situ ITAs were grafted to the left coronary system. RAs were used in 848 patients (93%) receiving bilateral ITAs and 1906 patients (99.8%) receiving single ITAs. Survival data were obtained using the National Death Index. Separate 1:1 propensity score-matched analyses were performed for (1) bilateral ITA versus single ITA and (2) bilateral ITA incorporating a free right ITA versus single ITA and RAs. Among the 912 patients with bilateral ITAs, those receiving an in situ right ITA to the left coronary system were compared with those receiving a free right ITA. RESULTS In the propensity score-matched analysis comparing bilateral versus single ITAs (591 matched pairs), there were similar rates of 30-day mortality and deep sternal wound infection. Bilateral ITA use was associated with greater 15-year survival (79% ± 3.9% vs 67% ± 4.7%, P < .001). In the analysis between bilateral ITA incorporating a free right ITA versus single ITA + RAs (380 matched pairs), bilateral ITA use demonstrated comparable survival at 15 years (79% ± 4.7% vs 67% ± 5.7%, P = .09). Among patients receiving bilateral ITAs, comparison between in situ right ITA versus free right ITA recipients (206 matched pairs) revealed comparable 15-year survival (84% ± 6.1% vs 79% ± 6.7%, P = .13). Multivariable Cox regression found bilateral ITA use to be protective from mortality (hazard ratio, 0.73; 95% confidence interval, 0.59-0.90, P = .004). CONCLUSIONS The use of bilateral ITAs as an in situ or free conduit is associated with greater survival and seems to offer a prognostic advantage over the use of only a single ITA supplemented by RAs. Therefore, all configurations of TAR are not equivalent.

Heart transplantation in Fontan patients across Australia and New Zealand

Objective Patients with Fontan physiology may eventually require heart transplantation (HT). We determined the rates and outcomes of HT in a national, population-based multicentre study. Methods From 1990 to 2015, 1369 patients underwent the Fontan procedure as recorded in the Australia and New Zealand Fontan Registry. We identified those who underwent HT and analysed their outcomes. We compared rates of HT between two catchment areas. In area 1 (n=721), patients were referred to the national paediatric HT programme or its associated adult programme. In area 2 (n=648), patients were referred to the national paediatric HT programme or one of the other adult HT programmes. Results Mean follow-up time post-Fontan was 11±8 years. Freedom from Fontan failure was 74%±3.9% at 20 years. HT was performed in 34 patients. Patients living in area 1 were more likely to have HT (4.0%, 29/721 vs 0.8%, 5/648, p<0.001) with a cumulative proportion of 3.4% vs 0.7% at 10 years and 6.8% vs 1.2% at 20 years (p=0.002). Area 1 patients were more likely to undergo HT (hazard ratio 4.7, 95% CI 1.7 to 13.5, p=0.003) on multivariable regression. Post-HT survival at 1, 5 and 10 years was 91%, 78% and 71%, respectively. Compared with other patients with congenital heart disease (n=87), Fontan patients had similar in-hospital outcomes and long-term survival. Conclusions Although HT after the Fontan procedure can be achieved with excellent outcomes, most patients with Fontan failure do not undergo HT. Significant regional differences in rates of HT in Fontan patients exist.

Is a third arterial conduit necessary? Comparison of the radial artery and saphenous vein in patients receiving bilateral internal thoracic arteries for triple vessel coronary disease.

OBJECTIVES The use of bilateral internal thoracic arteries (BITAs) is associated with improved long-term survival after coronary artery bypass grafting (CABG). However, it is unclear whether the addition of a radial artery (RA) in patients already receiving BITA confers any additional survival benefit over that of a saphenous vein (SV). As such, we reviewed our multicentre experience and compared both strategies. METHODS From 1995 to 2010, 1497 patients underwent primary isolated CABG for three-vessel coronary disease using BITAs. An SV was used as a third conduit in 460 (31%) patients and an RA in 1037 (69%). A total of 1258 distal anastomoses were performed using RAs and these were to the diagonal territory in 169, the circumflex in 454 and the right coronary in 635. Survival data were obtained using the National Death Index and propensity-score matching was used for risk-adjustment. RESULTS The overall cohort was young (mean age 61 ± 9 years). Patients receiving RAs were more likely to be younger, and were less likely to have experienced a prior myocardial infarction. At 30 days, mortality was similar (BITA + SV: 5, 1.1% vs BITA + RA: 9, 0.9%, P = 0.77). At 15 years, BITA + RA patients experienced improved unadjusted survival (BITA + SV: 67 ± 4.6% vs BITA + RA: 82 ± 3.2%, P < 0.0001). Multivariable Cox regression in the entire cohort also showed the BITA + RA group to be associated with better survival (HR 0.58, 95% CI 0.44-0.75, P < 0.001). After propensity-score matching of 262 patient-pairs, BITA + RA experienced similar 30-day mortality (BITA + SV: 3, 1.1% vs BITA + RA: 3, 1.1%, P > 0.99). However, at 15 years, BITA + RA patients experienced improved risk-adjusted survival (BITA + SV: 72 ± 6.0% vs BITA + RA: 82 ± 5.2%, P = 0.021). The RA was associated with better risk-adjusted survival for grafting of the right coronary and its branches (148 matched pairs; SV-RCA: 74 ± 7.8% vs RA-RCA: 86 ± 6.5%, P = 0.0046 at 15 years). CONCLUSIONS The addition of an RA graft even in patients already receiving BITAs is associated with a survival benefit. In younger patients with a reasonable long-term life expectancy, surgeons should strive to achieve total arterial revascularization with BITAs and radial arteries.

Major Depression in Cardiac Patients Is Accurately Assessed Using the Cardiac Depression Scale

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Postoperative Atrial Fibrillation After Isolated Aortic Valve Replacement: A Cause for Concern?

BACKGROUND Several studies have shown that postoperative atrial fibrillation (POAF) is associated with poorer short-term and long-term outcomes after general cardiac operations. There is, however, a paucity of data on the impact of POAF on outcomes after isolated aortic valve replacement (AVR). METHODS Data for all patients undergoing isolated first-time AVR between June 2001 and December 2009 was obtained from the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) National Cardiac Surgery Database Program and a retrospective analysis was conducted. Preoperative characteristics, early postoperative outcome, and late survival were compared between patients in whom POAF developed and those in whom it did not. Propensity score matching was performed to correct for differences between the 2 groups. RESULTS Excluding patients with preoperative arrhythmia, isolated first-time AVR was performed in 2,065 patients. POAF developed in 725 (35.1%) of them. Patients with POAF were significantly older (mean age, 72 versus 65 years; p < 0.001) and presented more often with comorbidities, including hypertension, respiratory disease, and hypercholesterolemia (all p < 0.05). From the initial study population, 592 propensity-matched patient pairs were derived; the overall matching rate was 81.7%. In the matched groups, 30-day mortality was not significantly different between the POAF and non-POAF groups (1.5% versus 1%; p = 0.48). Patients with POAF were, however, at an independently increased risk of perioperative complications, including new renal failure, gastrointestinal complications, and 30-day readmission (p < 0.05). Seven-year mortality was not significantly different between POAF and non-POAF groups (78% versus 83%; p = 0.63). CONCLUSIONS POAF is a risk factor for short-term morbidity but is not associated with a higher rate of early or late mortality after isolated AVR.

Extracorporeal Membrane Oxygenation Support in Postcardiotomy Elderly Patients: The Mayo Clinic Experience

BACKGROUND We conducted a retrospective study to assess whether providing extracorporeal membrane oxygenation (ECMO) support to elderly patients (aged 70 years or more) who failed separation from cardiopulmonary bypass after cardiac surgery was a viable option. METHODS From 2003 to 2013, 45 patients aged 70 years or more underwent 47 runs of ECMO postoperatively. RESULTS There were 31 men (68.9%). The mean age was 76.8 years. Five patients were in cardiogenic shock preoperatively. Forty-four patients required venoarterial ECMO support for cardiogenic shock. Mean duration of support was 103.8 ± 74.3 hours. Twenty-one patients (46.6%) died while on ECMO support. Twenty-four patients (53.3%) were weaned off ECMO initially, and 11 patients were discharged from hospital. Inhospital mortality was 75.6%. Postoperative complications included acute kidney injury in 30 patients (44.4%), pneumonia in 12 (26.7%), and sepsis in 11 (24.4%). There were 30 deaths (88.2%) attributable to cardiac causes. Preoperative atrial fibrillation, chronic kidney injury, lactic acidosis on ECMO support, and persistent coagulopathy were associated with higher mortality. CONCLUSIONS Postcardiotomy ECMO support in elderly patients is associated with high postoperative morbidity and mortality. Nevertheless, it often provides the last line of therapy for these critically ill patients and may provide positive outcomes in selected subgroups.