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Meidan TG, Lanfear AT, Squiers JJ, Hamandi M, Lytle BW, DiMaio JM, Smith RL. Robotic Mitral Valve Surgery After Prior Sternotomy. JTCVS Tech 2022; 13:46-51. [PMID: 35711230 PMCID: PMC9196136 DOI: 10.1016/j.xjtc.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
Objective Despite the recent increase in the use of minimally invasive approaches to mitral valve surgery in patients with a prior sternotomy, the outcomes of the robotic approach to mitral valve surgery in this patient population have not been examined. Methods We retrospectively reviewed 342 consecutive patients who underwent mitral valve surgery after a prior sternotomy between 2013 and 2020, in which the robotic approach was used in 21 patients (6.1%). We reviewed the clinical details of these 21 patients. Results The median age was 71 years [interquartile range 64.00, 74.00 years], and mean Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% ± 3.8%. The indication for mitral valve surgery was degenerative mitral valve disease in 33.3% (7/21), functional disease in 28.6% (6/21), mixed disease in 4.8% (1/21), rheumatic disease in 9.5% (2/21), and failed repair for degenerative disease in 23.8% (5/21). No cases required conversion from robotic assistance to alternative approaches, there were no intraoperative deaths, and intraoperative transesophageal echocardiogram confirmed complete elimination of mitral regurgitation in 90.5% (19/21) of cases. Thirty-day mortality was 0.0% (0/21), and 1-year mortality was 4.8% (1/21). There were no strokes or wound infections at 30 days, and 14.3% (3/21) of patients received intraoperative blood product transfusions. Conclusions The results of this retrospective review suggest that the robotic approach to mitral valve surgery in patients with a prior sternotomy is safe in experienced hands. Although some centers have considered prior sternotomy a relative contraindication to robotic mitral valve surgery, this approach is feasible and can be considered an option for experienced surgeons.
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Navia JL, Elgharably H, Hakim AH, Witten JC, Haupt MJ, Germano E, Houghtaling PL, Bakaeen FG, Pettersson GB, Lytle BW, Roselli EE, Gillinov AM, Svensson LG. Long-term Outcomes of Surgery for Invasive Valvular Endocarditis Involving the Aortomitral Fibrosa. Ann Thorac Surg 2019; 108:1314-1323. [DOI: 10.1016/j.athoracsur.2019.04.119] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
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Wojnarski CM, Roselli EE, Idrees JJ, Zhu Y, Carnes TA, Lowry AM, Collier PH, Griffin B, Ehrlinger J, Blackstone EH, Svensson LG, Lytle BW. Machine-learning phenotypic classification of bicuspid aortopathy. J Thorac Cardiovasc Surg 2018; 155:461-469.e4. [DOI: 10.1016/j.jtcvs.2017.08.123] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 07/27/2017] [Accepted: 08/28/2017] [Indexed: 01/08/2023]
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Lytle BW. Aortic valve replacement after bypass surgery: surgical (SAVR) or transcatheter (TAVR). J Thorac Dis 2017; 9:2714-2715. [PMID: 29221221 DOI: 10.21037/jtd.2017.08.76] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Raza S, Hussain ST, Rajeswaran J, Ansari A, Trezzi M, Arafat A, Witten J, Ravichandren K, Riaz H, Javadikasgari H, Panwar S, Demirjian S, Shrestha NK, Fraser TG, Navia JL, Lytle BW, Blackstone EH, Pettersson GB. Value of surgery for infective endocarditis in dialysis patients. J Thorac Cardiovasc Surg 2017. [DOI: 10.1016/j.jtcvs.2017.02.063] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Svensson LG, Pillai ST, Rajeswaran J, Desai MY, Griffin B, Grimm R, Hammer DF, Thamilarasan M, Roselli EE, Pettersson GB, Gillinov AM, Navia JL, Smedira NG, Sabik JF, Lytle BW, Blackstone EH. Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement. J Thorac Cardiovasc Surg 2015; 151:764-774.e4. [PMID: 26778214 DOI: 10.1016/j.jtcvs.2015.10.113] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 10/23/2015] [Accepted: 10/27/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies. METHODS From January 1995 to January 2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n = 261); composite biologic graft (n = 297); composite mechanical graft (n = 156); or allograft root (n = 243). RESULTS Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19% allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation (P < .05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57% at 15 years vs 14%-26% for the remaining procedures, P < .0001), because they were substantially older and had more comorbidities (P < .0001). CONCLUSIONS These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly.
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Desai MY, Smedira NG, Bhonsale A, Thamilarasan M, Lytle BW, Lever HM. Symptom assessment and exercise impairment in surgical decision making in hypertrophic obstructive cardiomyopathy: Relationship to outcomes. J Thorac Cardiovasc Surg 2015; 150:928-35.e1. [DOI: 10.1016/j.jtcvs.2015.07.063] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/01/2015] [Accepted: 07/16/2015] [Indexed: 10/23/2022]
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Maron BJ, Dearani JA, Ommen SR, Maron MS, Schaff HV, Nishimura RA, Ralph-Edwards A, Rakowski H, Sherrid MV, Swistel DG, Balaram S, Rastegar H, Rowin EJ, Smedira NG, Lytle BW, Desai MY, Lever HM. Low Operative Mortality Achieved With Surgical Septal Myectomy. J Am Coll Cardiol 2015; 66:1307-1308. [DOI: 10.1016/j.jacc.2015.06.1333] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 11/17/2022]
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Szeto WY, Svensson LG, Rajeswaran J, Ehrlinger J, Suri RM, Smith CR, Mack M, Miller DC, McCarthy PM, Bavaria JE, Cohn LH, Corso PJ, Guyton RA, Thourani VH, Lytle BW, Williams MR, Webb JG, Kapadia S, Tuzcu EM, Cohen DJ, Schaff HV, Leon MB, Blackstone EH. Appropriate patient selection or health care rationing? Lessons from surgical aortic valve replacement in the Placement of Aortic Transcatheter Valves I trial. J Thorac Cardiovasc Surg 2015; 150:557-68.e11. [DOI: 10.1016/j.jtcvs.2015.05.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/22/2015] [Accepted: 05/06/2015] [Indexed: 10/23/2022]
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Svensson LG, Blackstone EH, Apperson-Hansen C, Ruggieri PM, Ainkaran P, Naugle RI, Lima B, Roselli EE, Cooper M, Somogyi D, Tuzcu EM, Kapadia S, Clair DG, Sabik JF, Lytle BW. Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial. J Thorac Cardiovasc Surg 2015; 150:1140-7.e11. [PMID: 26409997 DOI: 10.1016/j.jtcvs.2015.07.054] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The study objective was to perform a randomized trial of brain protection during total aortic arch replacement and identify the best way to assess brain injury. METHODS From June 2003 to January 2010, 121 evaluable patients were randomized to retrograde (n = 60) or antegrade (n = 61) brain perfusion during hypothermic circulatory arrest. We assessed the sensitivity of clinical neurologic evaluation, brain imaging, and neurocognitive testing performed preoperatively and 4 to 6 months postoperatively to detect brain injury. RESULTS A total of 29 patients (24%) experienced neurologic events. Clinical stroke was evident in 1 patient (0.8%), and visual changes were evident in 2 patients; all had brain imaging changes. A total of 14 of 95 patients (15%) undergoing both preoperative and postoperative brain imaging had evidence of new white or gray matter changes; 10 of the 14 patients had neurocognitive testing, but only 2 patients experienced decline. A total of 17 of 96 patients (18%) undergoing both preoperative and postoperative neurocognitive testing manifested declines of 2 or more reliable change indexes; of these 17, 11 had neither imaging changes nor clinical events. Thirty-day mortality was 0.8% (1/121), with no neurologic deaths and a similar prevalence of neurologic events after retrograde and antegrade brain perfusion (22/60, 37% and 15/61, 25%, respectively; P = .2). CONCLUSIONS Although this randomized clinical trial revealed similar neurologic outcomes after retrograde or antegrade brain perfusion for total aortic arch replacement, clinical examination for postprocedural neurologic events is insensitive, brain imaging detects more events, and neurocognitive testing detects even more. Future neurologic assessments for cardiovascular procedures should include not only clinical examination but also brain imaging studies, neurocognitive testing, and long-term assessment.
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Wojnarski CM, Svensson LG, Roselli EE, Idrees JJ, Lowry AM, Ehrlinger J, Pettersson GB, Gillinov AM, Johnston DR, Soltesz EG, Navia JL, Hammer DF, Griffin B, Thamilarasan M, Kalahasti V, Sabik JF, Blackstone EH, Lytle BW. Aortic Dissection in Patients With Bicuspid Aortic Valve-Associated Aneurysms. Ann Thorac Surg 2015. [PMID: 26209494 DOI: 10.1016/j.athoracsur.2015.04.126] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Data regarding the risk of aortic dissection in patients with bicuspid aortic valve and large ascending aortic diameter are limited, and appropriate timing of prophylactic ascending aortic replacement lacks consensus. Thus our objectives were to determine the risk of aortic dissection based on initial cross-sectional imaging data and clinical variables and to isolate predictors of aortic intervention in those initially prescribed serial surveillance imaging. METHODS From January 1995 to January 2014, 1,181 patients with bicuspid aortic valve underwent cross-sectional computed tomography (CT) or magnetic resonance imaging (MRI) to ascertain sinus or tubular ascending aortic diameter greater than or equal to 4.7 cm. Random Forest classification was used to identify risk factors for aortic dissection, and among patients undergoing surveillance, time-related analysis was used to identify risk factors for aortic intervention. RESULTS Prevalence of type A dissection that was detected by imaging or was found at operation or on follow-up was 5.3% (n = 63). Probability of type A dissection increased gradually at a sinus diameter of 5.0 cm--from 4.1% to 13% at 7.2 cm--and then increased steeply at an ascending aortic diameter of 5.3 cm--from 3.8% to 35% at 8.4 cm--corresponding to a cross-sectional area to height ratio of 10 cm(2)/m for sinuses of Valsalva and 13 cm(2)/m for the tubular ascending aorta. Cross-sectional area to height ratio was the best predictor of type A dissection (area under the curve [AUC] = 0.73). CONCLUSIONS Early prophylactic ascending aortic replacement in patients with bicuspid aortic valve should be considered at high-volume aortic centers to reduce the high risk of preventable type A dissection in those with aortas larger than approximately 5.0 cm or with a cross-sectional area to height ratio greater than approximately 10 cm(2)/m.
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Patel P, Dhillon A, Popovic ZB, Smedira NG, Rizzo J, Thamilarasan M, Agler D, Lytle BW, Lever HM, Desai MY. Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy Patients Without Severe Septal Hypertrophy. Circ Cardiovasc Imaging 2015; 8:e003132. [DOI: 10.1161/circimaging.115.003132] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In patients with hypertrophic cardiomyopathy and left ventricular outflow tract (LVOT) obstruction, but without basal septal hypertrophy, we sought to identify mitral valve (MV) and papillary muscle (PM) abnormalities that predisposed to LVOT obstruction, using echo and cardiac magnetic resonance.
Methods and Results—
We studied 121 patients with hypertrophic cardiomyopathy hypertrophic cardiomyopathy (age, 49±17 years; 60% men; 57% on β-blockers) with a basal septal thickness of ≤1.8 cm who underwent echocardiography (rest+stress) and cine cardiac magnetic resonance. Echo measurements included maximal LVOT gradient (rest/provocable), MV leaflet length (parasternal long, 4 and 3-chamber views), and abnormal chordal attachment to mid/base of anterior MV. Cine cardiac magnetic resonance measurements included basal septal thickness, number/area of PM heads, and bifid PM mobility (in systole and diastole). Mean basal septal thickness, LVOT gradient, and LV ejection fraction were 1.5±0.3 cm, 72±54 mm Hg, and 61±6%, respectively. The number of anterolateral and posteromedial PM heads was 2.7±0.7 and 2.6±0.7, respectively. Anterolateral and posteromedial PM areas were 19.9±7 cm
2
and 17.1±6 cm
2
, respectively. PM mobility was 11±6°. On multivariable analysis, predictors of maximal LVOT gradient were basal septal thickness, bifid PM mobility, anterior mitral leaflet length, and abnormal chordal attachment to base of anterior mitral leaflet. Forty-five patients underwent surgery to relieve LVOT obstruction, of which 52% needed an additional nonmyectomy (MV repair/replacement or PM reorientation) approach.
Conclusions—
In hypertrophic cardiomyopathy patients without significant LV hypertrophy, in addition to basal septal thickness, anterior MV length, abnormal chordal attachment, and bifid PM mobility are associated with LVOT obstruction. In such patients, additional procedures on MV and PM (±myectomy) could be considered.
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Parikh R, Goodman AL, Barr T, Sabik JF, Svensson LG, Rodriguez LL, Lytle BW, Grimm RA, Griffin BP, Desai MY. Outcomes of surgical aortic valve replacement for severe aortic stenosis: Incorporation of left ventricular systolic function and stroke volume index. J Thorac Cardiovasc Surg 2015; 149:1558-66.e1. [DOI: 10.1016/j.jtcvs.2015.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/25/2015] [Accepted: 03/07/2015] [Indexed: 11/16/2022]
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Johnston DR, Soltesz EG, Vakil N, Rajeswaran J, Roselli EE, Sabik JF, Smedira NG, Svensson LG, Lytle BW, Blackstone EH. Long-term durability of bioprosthetic aortic valves: implications from 12,569 implants. Ann Thorac Surg 2015; 99:1239-47. [PMID: 25662439 DOI: 10.1016/j.athoracsur.2014.10.070] [Citation(s) in RCA: 329] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 10/28/2014] [Accepted: 10/31/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Increased life expectancy and younger patients' desire to avoid lifelong anticoagulation requires a better understanding of bioprosthetic valve failure. This study evaluates risk factors associated with explantation for structural valve deterioration (SVD) in a long-term series of Carpentier-Edwards PERIMOUNT aortic valves (AV). METHODS From June 1982 to January 2011, 12,569 patients underwent AV replacement with Edwards Lifesciences Carpentier-Edwards PERIMOUNT stented bovine pericardial prostheses, models 2700PM (n = 310) or 2700 (n = 12,259). Mean age was 71 ± 11 years (range, 18 to 98 years). 93% had native AV disease, 48% underwent concomitant coronary artery bypass grafting, and 26% had additional valve surgery. There were 81,706 patient-years of systematic follow-up data available for analysis. Demographics, intraoperative variables, and 27,386 echocardiographic records were used to identify risks for explant for SVD and assess longitudinal changes in transprosthesis gradients using time-varying covariable analyses. RESULTS Three hundred fifty-four explants were performed, with 41% related to endocarditis and 44% to SVD. Actuarial estimates of explant for SVD at 10 and 20 years were 1.9% and 15% overall, respectively, and in patients younger than 60 years, 5.6% and 46%, respectively. Younger age (p < 0.0001), lipid-lowering drugs (p = 0.002), prosthesis-patient mismatch (p = 0.001), and higher postoperative peak and mean AV gradients were associated with explant for SVD (p < 0.0001). The effect of gradient on SVD was greatest in patients younger than 60 years. CONCLUSIONS Durability of the Carpentier-Edwards PERIMOUNT aortic valve is excellent even in younger patients. Explant for SVD is related to gradient at implantation, especially in younger patients. Strategies to reduce early postoperative AV gradients, such as root enlargement or more efficient prostheses, should be considered.
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Roselli EE, Loor G, He J, Rafael AE, Rajeswaran J, Houghtaling PL, Svensson LG, Blackstone EH, Lytle BW. Distal aortic interventions after repair of ascending dissection: The argument for a more aggressive approach. J Thorac Cardiovasc Surg 2015; 149:S117-24.e3. [DOI: 10.1016/j.jtcvs.2014.11.029] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 11/01/2014] [Accepted: 11/07/2014] [Indexed: 12/27/2022]
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Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg 2015; 149:144-51. [DOI: 10.1016/j.jtcvs.2014.07.109] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 07/13/2014] [Indexed: 10/24/2022]
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Dhillon A, Sweet W, Popovic ZB, Smedira NG, Thamilarasan M, Lytle BW, Tan C, Starling RC, Lever HM, Moravec CS, Desai MY. Association of noninvasively measured left ventricular mechanics with in vitro muscle contractile performance: a prospective study in hypertrophic cardiomyopathy patients. J Am Heart Assoc 2014; 3:e001269. [PMID: 25389286 PMCID: PMC4338715 DOI: 10.1161/jaha.114.001269] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hypertrophic cardiomyopathy (HCM) is a primary myopathic process in which regional left ventricular dysfunction may exist without overt global left ventricular dysfunction. In obstructive HCM patients who underwent surgical myectomy (SM), we sought to determine if there is a significant association between echocardiographic longitudinal strain, histopathology, and in vitro myocardial performance (resting tension and developed tension) of the surgical specimen. Methods and Results HCM patients (n=122, 54±14 years, 54% men) undergoing SM were prospectively recruited. Longitudinal systolic strain and diastolic strain rates were measured at that basal septum (partially removed at SM) by using velocity vector imaging on preoperative echocardiography. Semiquantitative histopathologic grading of myocyte disarray and fibrosis and in vitro measurements of resting tension and developed tension were made in septal tissue obtained at SM. Mean basal septal systolic strain and diastolic strain rate were −8.3±5% and 0.62±0.4/s, while mild or greater degree of myocyte disarray and interstitial fibrosis were present in 85% and 87%, respectively. Mean resting tension and developed tension were 2.8±1 and 1.4±0.8 g/mm2. On regression analysis, basal septal systolic strain, diastolic strain rate, disarray, and fibrosis were associated with developed tension (β=0.19, 0.20, −0.33, and −0.40, respectively, all P<0.01) and resting tension (β=0.21, 0.22, −0.25, and −0.28, respectively, all P<0.01). Conclusion In obstructive HCM patients who underwent SM, left ventricular mechanics (echocardiographic longitudinal systolic strain and diastolic strain rates), assessed at the basal septum (myocardium removed during myectomy) and histopathologic findings characteristic for HCM (disarray and fibrosis) were significantly associated with in vitro myocardial resting and developed contractile performance.
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Monteleone PP, Shrestha NK, Jacob J, Gordon SM, Fraser TG, Rehm SJ, Bajzer CT, Kapadia SR, Pettersson GB, Lytle BW, Blackstone EH, Shishehbor MH. Clinical utility of cerebral angiography in the preoperative assessment of endocarditis. Vasc Med 2014; 19:500-6. [DOI: 10.1177/1358863x14557152] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Cerebral angiography is an invasive procedure utilized without supporting guidelines in preoperative evaluations of infective endocarditis (IE). It is used to identify mycotic intracranial aneurysm, which is suspected to increase the risk of intracranial bleeding during cardiac surgery. Our objectives were to: (1) assess the utility of cerebral angiography by determining which subset of IE patients benefit from its performance; and (2) identify clinical and noninvasive screening tests that can preclude the need for invasive cerebral angiography. Retrospective analysis was performed of all patients treated surgically for IE from 7/2007 to 1/2012 and discharged with medical treatment for IE from 7/2007 to 7/2009 presenting to a large academic center. Of the 151 patients who underwent cerebral angiography, mycotic aneurysm was identified in seven (prevalence=4.6%; 95% CI 2.3–9.3%). Five had viridans group streptococci as the causative IE microorganism ( p=0.0017). Noninvasive imaging and particularly absence of intracranial bleed on magnetic resonance imaging conveys a negative predictive value (NPV) of 0.977 (95% CI 0.879–0.996). Absence of a focal neurologic deficit or altered mental status convey a NPV of 0.990 (95% CI 0.945–0.998) and 0.944 (95% CI 0.883–0.974), respectively. Clinical suspicion for mycotic aneurysm and thus utilization of cerebral angiography is likely necessary only in the setting of acute neurologic deficits and when noninvasive imaging demonstrates acute intracranial bleed. A novel association between viridans group streptococci and intracranial mycotic aneurysm is demonstrated.
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Aguirre J, Waskowski R, Poddar K, Kapadia S, Krishnaswamy A, McCullough R, Mick S, Navia JL, Roselli EE, Tuzcu ME, Sabik JF, Lytle BW, Svensson LG. Transcatheter aortic valve replacement: Experience with the transapical approach, alternate access sites, and concomitant cardiac repairs. J Thorac Cardiovasc Surg 2014; 148:1417-22. [DOI: 10.1016/j.jtcvs.2014.05.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/21/2014] [Accepted: 05/08/2014] [Indexed: 11/28/2022]
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Desai MY, Karunakaravel K, Wu W, Agarwal S, Smedira NG, Lytle BW, Griffin BP. Pulmonary fibrosis on multidetector computed tomography and mortality in patients with radiation-associated cardiac disease undergoing cardiac surgery. J Thorac Cardiovasc Surg 2014; 148:475-81.e3. [DOI: 10.1016/j.jtcvs.2013.08.087] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/12/2013] [Accepted: 08/29/2013] [Indexed: 11/27/2022]
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Raza S, Sabik JF, Masabni K, Ainkaran P, Lytle BW, Blackstone EH. Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus. J Thorac Cardiovasc Surg 2014; 148:1257-1264; discussion 1264-6. [PMID: 25260269 DOI: 10.1016/j.jtcvs.2014.06.058] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/17/2014] [Accepted: 06/27/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To identify surgical revascularization techniques that minimize surgical risk and maximize late survival in patients with diabetes undergoing coronary artery bypass grafting (CABG). METHODS From January 1972 to January 2011, 11,922 patients with diabetes underwent primary isolated CABG. The revascularization techniques investigated included bilateral internal thoracic artery (BITA) grafting (n=938; 7.9%) versus single ITA (SITA) grafting, off-pump (n=602; 5.0%) versus on-pump CABG, and incomplete (n=2109; 18%) versus complete revascularization. The median follow-up was 7.8 years and total follow-up, 104,516 patient-years. Multivariable analyses were performed to assess the effects of surgical techniques on hospital outcomes and long-term mortality. RESULTS After adjusting for patient characteristics, BITA versus SITA grafting was associated with a 21% lower late mortality (68% confidence limits, 16%-26%). However, BITA grafting was also associated with more deep sternal wound infections (DSWIs), but the considerable mortality from DSWI minimally affected overall survival because of its rare occurrence. The risk factors for DSWI were female sex (80% increased risk), higher body mass index (7% increased risk per kg/m2), medically treated diabetes (73% increased risk), previous myocardial infarction (58% increased risk), and peripheral arterial disease (73% increased risk). Off-pump and on-pump CABG had similar results. Complete versus incomplete revascularization had similar hospital outcomes; however, complete revascularization was associated with 10% lower late mortality (68% confidence limits, 7.0%-13%). CONCLUSIONS BITA grafting with complete revascularization maximizes long-term survival and is recommended for patients with diabetes undergoing CABG. BITA grafting should be used in all patients with diabetes whose risk of DSWI is low. It might be best avoided in obese diabetic women with diffuse atherosclerotic burden-those at greatest risk of developing these infections.
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Pettersson GB, Hussain ST, Ramankutty RM, Lytle BW, Blackstone EH. Reconstruction of fibrous skeleton: technique, pitfalls and results. Multimed Man Cardiothorac Surg 2014; 2014:mmu004. [PMID: 24947975 DOI: 10.1093/mmcts/mmu004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Destruction of the mitral-aortic (or mitroaortic) intervalvular fibrosa (IVF) by infective endocarditis is a marker of advanced pathology. Patients are at high risk, as they are sicker, have more comorbidities and have more advanced pathology, requiring a difficult operation that includes debriding and reconstructing the IVF. The anatomy and surgical techniques for that reconstruction are presented and discussed. Operative risk is high and remains high for the first year, before becoming equivalent to that of conventional operations for endocarditis. Current outcomes are better than in the past, but there is room for further improvement.
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Kobayashi T, Dhillon A, Popovic Z, Bhonsale A, Smedira NG, Thamilarasan M, Lytle BW, Lever HM, Desai MY. Differences in global and regional left ventricular myocardial mechanics in various morphologic subtypes of patients with obstructive hypertrophic cardiomyopathy referred for ventricular septal myotomy/myectomy. Am J Cardiol 2014; 113:1879-85. [PMID: 24837268 DOI: 10.1016/j.amjcard.2014.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 03/06/2014] [Accepted: 03/06/2014] [Indexed: 11/24/2022]
Abstract
Patients with obstructive hypertrophic cardiomyopathy (HC) have various left ventricular (LV) shapes: reverse septal curvature (RSC, commonly familial), sigmoid septum (SS, common in hypertensives), and concentric hypertrophy (CH). Longitudinal (systolic and early diastolic) strain rate (SR) is sensitive in detecting regional myocardial dysfunction. We sought to determine differences in longitudinal SR of patients with obstructive HC, based on LV shapes. We studied 199 consecutive patients with HC (50% men) referred for surgical myectomy. Clinical and echocardiographic parameters were recorded. LV shapes were classified on echocardiography, using basal septal 1/3 to posterior wall ratio: RSC = ratio >1.3 (extending to mid and distal septum), SS = ratio >1.3 (extending only to basal 1/3), and concentric = ratio ≤1.3. Longitudinal systolic and early diastolic SRs were measured from apical 4- and 2-chamber views (VVI 2.0; Siemens, Erlangen). Distribution of RSC, SS, and CH was 50%, 28%, and 22%, respectively. Patients with RSC were significantly younger (47 ± 12 vs 64 ± 10 and 57 ± 11, respectively) with lower hypertension (40% vs 71% and 67%, respectively) than patients with SS or CH (both p <0.001). Patients with RSC had lower global systolic (-0.99 ± 0.3 vs -1.05 ± 0.3 and -1.17 ± 0.3) and early diastolic SR (0.95 ± 0.4 vs 0.98 ± 0.3 and 1.16 ± 0.4) versus patients with SS and CH (in 1/s, both p <0.01), despite being much younger and less hypertensive. RSC was associated with abnormal global LV systolic (beta 0.16) and early diastolic (beta -0.17) SR (both p <0.01). In conclusion, patients with HC with RCS have significantly abnormal LV mechanics, despite being younger and less hypertensive. A combination of LV mechanics and shapes could help differentiate between genetically mediated and other causes of obstructive HC.
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Svensson LG, Al Kindi AH, Vivacqua A, Pettersson GB, Gillinov AM, Mihaljevic T, Roselli EE, Sabik JF, Griffin B, Hammer DF, Rodriguez L, Williams SJ, Blackstone EH, Lytle BW. Long-Term Durability of Bicuspid Aortic Valve Repair. Ann Thorac Surg 2014; 97:1539-47; discussion 1548. [DOI: 10.1016/j.athoracsur.2013.11.036] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 11/13/2013] [Accepted: 11/19/2013] [Indexed: 02/03/2023]
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Kapadia SR, Svensson LG, Roselli E, Schoenhagen P, Popovic Z, Alfirevic A, Barzilai B, Krishnaswamy A, Stewart W, Mehta A, Lal Poddar K, Parashar A, Modi D, Ozkan A, Khot U, Lytle BW, Murat Tuzcu E. Single center TAVR experience with a focus on the prevention and management of catastrophic complications. Catheter Cardiovasc Interv 2014; 84:834-42. [PMID: 24407775 PMCID: PMC4231228 DOI: 10.1002/ccd.25356] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 12/13/2013] [Accepted: 01/03/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is an important treatment option for patients with severe symptomatic aortic stenosis (AS) who are inoperable or at high risk for complications with surgical aortic valve replacement. We report here our single-center data on consecutive patients undergoing transfemoral (TF) TAVR since the inception of our program, with a special focus on minimizing and managing complications. METHODS The patient population consists of all consecutive patients who underwent an attempted TF-TAVR at our institution, beginning with the first proctored case in May 2006, through December 2012. Clinical, procedural, and echocardiographic data were collected by chart review and echo database query. All events are reported according to Valve Academic Research Consortium-2. RESULTS During the study period, 255 patients with AS had attempted TF-TAVR. The procedure was successful in 244 (95.7%) patients. Serious complications including aortic annular rupture (n = 2), coronary occlusion (n = 2), iliac artery rupture (n = 1), and ventricular embolization (n = 1) were successfully managed. Death and stroke rate at 30 days was 0.4% and 1.6%, respectively. One-year follow-up was complete in 171 (76%) patients. One-year mortality was 17.5% with a 3.5% stroke rate. Descending aortic rupture, while advancing the valve, was the only fatal procedural event. There were 24.4% patients with ≥2+ aortic regurgitation. CONCLUSIONS TAVR can be accomplished with excellent safety in a tertiary center with a well-developed infrastructure for the management of serious complications. The data presented here provide support for TAVR as an important treatment option, and results from randomized trials of patients with lower surgical risk are eagerly awaited.
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