Valve-Preserving Root Reimplantation Combined with Arch Procedure: Optimizing Patient Selection

OBJECTIVE

Patients with thoracic aortic disease commonly present with concomitant multisegment pathology. We describe the patient population, analyze outcomes, and define the patient selection strategy for valve-preserving aortic root reimplantation (VPARR) combined with the arch procedure. Methods: From 2008 to 2018, 98 patients underwent VPARR combined with the aortic arch procedure (hemi-arch, 50% [n = 49, limited repair]; total arch, 50% [n = 49, complete repair] including 39 with elephant trunk). Indications for surgery were aneurysmal disease (61%) and aortic dissection (39%). The median follow-up was 17 months (IQR, 8 to 60 months). Results: There were no operative deaths or paraplegia, and 5 patients underwent re-exploration for bleeding. During follow-up, 2 patients required aortic valve replacement for severe aortic insufficiency at 1 and 5 years, and 4 patients died. In the limited repair group, 1 patient underwent reintervention for aortic arch replacement, whereas 4 patients underwent planned intervention (1 endovascular and 3 open thoracoabdominal aortic repair). In the complete repair group, 23 patients underwent planned intervention (15 endovascular and 8 open thoracoabdominal repair). Conclusions: Single-stage, complete, proximal aortic repair including VPARR combined with total aortic arch replacement is as safe and feasible to perform as limited arch repair and facilitates further intervention in carefully selected patients with diffuse aortic pathology at centers of expertise.

Lung Transplant for Patients with COVID-19 Bridged with VV ECMO: Initial Experience

Purpose

During the COVID-19 pandemic, veno-venous Extracorporeal Membrane Oxygenation (VV ECMO) has been used extensively for respiratory failure refractory to conventional mechanical ventilation (MV) and rescue maneuvers. However, the worldwide experience with COVID-19 patients undergoing lung transplant (LTx) with pre-LTx VV ECMO support is limited. Therefore, we sought to report our institution's early experience with COVID-19 patients who underwent LTx after VV ECMO.

Methods

We retrospectively identified 5 COVID-19 patients who underwent LTx after VV ECMO support. Patients were required to have a negative nasopharyngeal swab and a negative bronchoalveolar lavage for COVID-19 prior to LTx listing. We analyzed preoperative and operative characteristics, details of VV ECMO support and early post-transplant outcomes.

Results

The mean age of our cohort was 50 years (range 39-57 years) and all patients were male. Mean recipient BMI was 30 (range 22-37). Mean duration of VV ECMO pre-Ltx was 60 days (range 44-72 days). At the time of the LTx operation, 60% (3/5) of patients were on VV ECMO, 20% (1/5) were on mechanical ventilation (MV), and 20% (1/5) were on supplemental oxygen only. Preoperatively, 80% (4/5) had acute kidney injury and 20% (2/5) were on dialysis. LTx was performed via clamshell approach with intraoperative venoaterial ECMO support in all cases. For 60% (3/5) patients, VV ECMO support was continued after LTx and discontinued on postoperative days 0, 1 and 6, respectively. All-cause mortality was 40% (2/5), related to sepsis and multi-organ failure, and both deaths occurred an average of 115 days post-LTx. Mean length of stay for surviving patients was 59 days (range 22-117). In the first 3 months postop-LTx, grade A2 acute cellular rejection was noted in 2 patients, A1 in 2 patients, and antibody-mediated rejection in 1 patient.

Conclusion

Our early experience with LTx for COVID-19 patients supported with VV ECMO support is notable for 1) prolonged VV-ECMO duration and significant morbidity pre-LTx, and 2) early mortalities related to sepsis and multiple organ failure. These data highlight a uniquely complex patient population that carries high risk of multi-organ failure and other comorbidities dictating careful selection for transplant.

Bilateral sequential lung transplantation: technical aspects

The surgical technique for lung transplantation has evolved dramatically over the last three decades. Significant improvements in short term outcomes in the early years of lung transplantation were due, in large part, to techniques developed to reduce airway anastomotic complications in single lung transplantation. Following development of the technique of en bloc double lung transplantation, evolution to the bilateral sequential technique further reduced airway complications for double lung transplantation. More recently, some programs have utilized the en bloc double lung transplant technique with bronchial artery revascularization to aid airway healing and potentially improve short- and long-term outcomes. The experience with bronchial artery revascularization remains limited to a few series, with the technique having not been widely adopted by most lung transplant programs. With the implementation of priority allocations schemes in many countries, patients with higher risk profiles are being prioritized for transplantation which results in more complex procedures in fragile recipients with multiple comorbidities. This includes the increased need for concomitant cardiac procedures as well as performing lung transplantation after prior cardiothoracic surgery. Different surgical approaches have been described for bilateral sequential lung transplantation with or without intra-operative mechanical circulatory support (MCS), such as sternotomy, clamshell (bilateral anterior thoracotomies with transverse sternotomy), and bilateral thoracotomy incisions. Herein, we aim, not only to describe the various surgical approaches for double lung transplantation, but to provide a comprehensive review of other aspects related to the recipient pathology and different anatomical variants as well as handling technical challenges that might be encountered during the procedure.

Current era left ventricular assist devices

Left ventricular assist devices (LVADs) have changed the landscape of treatment options for patients with end stage heart failure. Due to the limited availability of donor hearts for transplantation, LVADs have become an important option for many of these patients. Much progress has been made in the device industry since then, and newer devices continue to improve patient outcomes. In this review, we will discuss some of the key transitions in LVADs over the years, the current LVADs used in practice today, implantation techniques, the impact of the new heart allocation system on LVAD use and future prospective LVADs.

More Than a Simple Vegetation: The Trifecta of Mitral Valve Leaflet Perforation, Windsock Aneurysm, and Mitral Valve Abscess

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MV abscesses and aneurysms are uncommon complications of IE.

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Serial echocardiography is important to identify perivalvular complications.

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Three-dimensional transesophageal echocardiography has incremental value in diagnosis.

Serious Gastrointestinal Complications After Cardiac Surgery and Associated Mortality

BACKGROUND

Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality.

METHODS

We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality.

RESULTS

Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P < .001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P < .001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality.

CONCLUSIONS

Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.

Right versus left heart reverse remodelling after treating ischaemic mitral and tricuspid regurgitation

OBJECTIVES

Repair outcomes of tricuspid regurgitation (TR) associated with ischaemic mitral regurgitation (IMR) are inferior to functional TR in terms of TR recurrence and right ventricular (RV) reverse remodelling. Our objective is to analyse right versus left heart reverse remodelling after surgery for IMR-associated TR.

METHODS

From 2001 to 2011, 568 patients with severe IMR underwent mitral valve surgery (repair 87%, replacement 13%), and 131 had concomitant tricuspid valve repair. Median follow-up was 3.0 years; 25% of living patients were followed up for 6.3 years. Longitudinal analysis of 1527 follow-up echocardiograms was performed to assess ventricular reverse remodelling and function.

RESULTS

Unlike the left heart, the right heart failed to reverse remodel (failed to recover ventricular function or halt dilatation). During follow-up after surgery, the right ventricle continued to dilate while the left ventricle regressed in size. RV ejection fraction decreased (46% at 1 month and 44% at 5 years), while left ventricular ejection fraction increased (33% and 37%, respectively). RV strain showed early (-11% at 1 month) and late (-12% at 5 years) dysfunction. Patients who underwent tricuspid valve repair had worse RV function. Mitral regurgitation remained stable after surgical intervention, and TR gradually recurred (37% moderate, 20% severe at 7 years).

CONCLUSIONS

Surgical treatment of IMR and TR along with revascularization failed to induce reverse remodelling of the right heart. These findings warrant further investigations to identify optimal timing and approach of intervention for IMR-associated TR with respect to RV remodelling.

Comparison of mechanical cardiopulmonary support strategies during lung transplantation

INTRODUCTION

Lung transplantation outcomes are influenced by the intraoperative mechanical cardiopulmonary support strategy used. This surgery was historically done either on cardiopulmonary bypass (CPB) or off pump. Recently, there has been increased interest in intraoperative support with veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO). However, there is a lack of consensus on the relative risks, benefits and indications for each intraoperative support strategy.

AREAS COVERED

This review includes information from cohort studies, case-control studies, and case series that compare morbidity and/or mortality of two or more intraoperative cardiopulmonary support strategies during lung transplantation.

EXPERT OPINION

The optimal strategy for intraoperative cardiopulmonary support during lung transplantation remains an area of debate. Current data suggest that off pump is associated with better outcomes and could be considered whenever feasible. ECMO is generally associated with preferable outcomes to CPB, but the data supporting this association is not robust. Interestingly, whether CPB is unplanned or prolonged might influence outcomes more than the use of CPB itself. These observations can help guide surgical teams in their approach for intraoperative mechanical support strategy during lung transplantation and should serve as the basis for further investigations.

"Holes-in-one": A case of concurrent windsock mitral valve, root abscess, and Gerbode defect

Infective endocarditis is a heterogeneous disease with a wide array of pathological lesions. We present a 55-year-old man with severe mitral and aortic regurgitation on transthoracic echocardiography. Transesophageal echocardiogram characterized the mechanisms detecting a windsock mitral valve perforation, aortic root abscess, and Gerbode ventricular septal defect, with the deep transgastric view showing all three pathologies concurrently. The etiologies of mitral valve perforation and Gerbode defects are discussed. Transesophageal echocardiography remains a critical imaging modality to diagnose and evaluate the extent of infective endocarditis with superior sensitivity to transthoracic echocardiography.

Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis

BACKGROUND

Little is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients.

METHODS

From 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion.

RESULTS

Two of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively.

CONCLUSIONS

Among patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.

HeartMate 3 Implantation in a Myosplint Device-Supported Left Ventricle

Implantation of a left ventricular assist device in a patient who has a passive cardiac support device can present a surgical challenge. This case demonstrates a safe and feasible surgical approach for HeartMate 3 (Abbott, Abbott Park, IL) implantation after remote Mysoplint device (Myocor, Maple Grove, MN) placement.