The Society of Thoracic Surgeons Risk Model for Operative Mortality After Multiple Valve Surgery

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Additional bypass graft or concomitant surgical ablation? Insights from the HEIST registry

BACKGROUND

Surgical ablation for atrial fibrillation at the time of isolated coronary artery bypass grafting is reluctantly attempted. Meanwhile, complete revascularization is not always possible in these patients. We attempted to counterbalance the long-term benefits of surgical ablation against the risks of incomplete revascularization.

METHODS

Atrial fibrillation patients undergoing isolated coronary artery bypass grafting for multivessel disease between 2012 to 2022 and included in the HEart surgery In atrial fibrillation and Supraventricular Tachycardia registry were divided into complete revascularization, complete revascularization with additional grafts, and incomplete revascularization cohorts; these were further split into surgical ablation and non-surgical ablation subgroups.

RESULTS

A total of 8,405 patients (78% men; age 69.3 ± 7.9) were included; of those, 5,918 (70.4%) had complete revascularization, and 556 (6.6%) had surgical ablation performed. Number of anastomoses was 2.7 ± 1.2. The median follow-up was 5.1 [interquartile range 2.1-8.8] years. In patients in whom complete revascularization was achieved, surgical ablation was associated with long-term survival benefit: hazard ratio 0.69; 95% confidence intervals (0.50-0.94); P = .020 compared with grafting additional lesions. Similarly, in patients in whom complete revascularization was not achieved, surgical ablation was associated with a long-term survival benefit of 0.68 (0.49-0.94); P = .019. When comparing surgical ablation on top of incomplete revascularization against complete revascularization without additional grafts or surgical ablation, there was no difference between the 2: 0.84 (0.61-1.17); P = .307, which was also consistent in the propensity score-matched analysis: 0.75 (0.39-1.43); P = .379.

CONCLUSION

To achieve complete revascularization is of utmost importance. However, when facing incomplete revascularization at the time of coronary artery bypass grafting in a patient with underlying atrial fibrillation, concomitant surgical ablation on top of incomplete revascularization is associated with similar long-term survival as complete revascularization without surgical ablation.

Sequential percutaneous tricuspid and pulmonary valve implantation in a young child operated previously for Ebstein Anomaly

We report a successful percutaneous tricuspid valve implantation followed by a percutaneous pulmonary valve implantation in a young child with Ebstein's anomaly of tricuspid valve and pulmonary stenosis who was previously treated surgically at 1 year of age with tricuspid ring annuloplasty and a transannular outflow patch. This article shows the feasibility of sequential implantation of two valves in young patients with severe tricuspid and pulmonary valve insufficiency.

Effect of perioperative oral management on postoperative bloodstream infection in heart valve surgery patients

OBJECTIVE

There is a well-known relationship between oral hygiene and infective endocarditis. Epidemiological evidence regarding perioperative oral management (POM) for cancer surgery has been accumulated, but this evidence is not sufficient for cardiac surgery. Therefore, our purpose was to investigate whether POM can prevent postoperative complications in patients undergoing heart valve surgery.

SUBJECTS AND METHODS

Using single-arm medical information, we retrospectively enrolled 301 patients who underwent heart valve surgery between April 2010 and March 2019. The patient background was adjusted by the propensity score (PS). We then analyzed the impact of POM on postoperative bloodstream infection (PBSI), postoperative pneumonia, and mortality using PS inverse probability of treatment weighting (IPTW).

RESULTS

IPTW revealed that the POM group had a lower incidence of PBSI than the control group, with an odds ratio of 0.316 (p = 0.003). The mortality in the POM group was significantly lower than that in the control group (p = 0.023). Fourteen patients died in the present study and 6 of them were infection-related.

CONCLUSIONS

POM was significantly associated with decreased incidence of PBSI and mortality. The results suggest that POM is beneficial for the prevention of PBSI and mortality in patients undergoing heart valve surgery.

Outcomes Following Triple Cardiac Valve Surgery Over 17-years: A Multicentre Population-Linkage Study

INTRODUCTION

Studies have reported increasing triple valve surgery (TVS, defined as concomitant aortic, mitral and tricuspid valves surgery) incidence and improved postoperative survival. The epidemiology and outcome of TVS is not known in Australia.

METHODS

From the Admission-Patient-Data-Collection registry, all New South Wales residents who underwent cardiac valve surgery between 1 July 2001 and 31 December 2018 were identified, with cause-specific mortality tracked from the death registry.

RESULTS

Triple valve surgery comprised 1.2% (347/28,667 cases) of all valvular surgeries. Volumes rose from eight cases-per-annum in 2002 to a peak of 37 in 2012, and between 23 and 30 cases-per-annum since. Mean (±SD) age of study cohort (n=340 persons) was 68.2±15.2 years (50% male); 20.3% had concomitant coronary-artery-bypass-surgery (males vs females: 29.4% vs 11.2%, p<0.001). Main surgery on aortic and mitral valves was replacement (95.9% and 70.6% respectively). Tricuspid valve annuloplasty was performed in 90.6% of patients. Cumulative in-hospital, 180-day, and total mortality (mean follow-up=4.9±4.0 yrs) was 7.4%, 11.8% and 42.6%, respectively. Heart failure (24.0% in-hospital, 22.5% post-discharge) and sepsis (24.0% in-hospital, 20.0% post-discharge) were the main cause-specific deaths. There was no in-hospital stroke-related death. Age (median >72 yrs; hazard ratio [HR]=1.95, 95%CI=1.37-2.79), malignancy (HR=6.35, 95%CI=2.21-18.26), heart failure (HR=1.79, 95%CI=1.25-2.57) and chronic kidney disease (CKD) (HR=2.21, 95%CI=1.39-3.51) (all p<0.005) were independent predictors during intermediate-term follow-up.

CONCLUSIONS

Triple valve surgery remains rare in Australia and is associated with high mortality. Multi-centred collaboration and access to comprehensive clinical data are required to identify the drivers of poor outcome.

Clinical Insights to Complete and Incomplete Surgical Revascularization in Atrial Fibrillation and Multivessel Coronary Disease

Objectives

Although endorsed by international guidelines, complete revascularization (CR) with Coronary Artery Bypass Grafting (CABG) remains underused. In higher-risk patients such as those with pre-operative atrial fibrillation (AF), the effects of CR are not well studied.

Methods

We analyzed patients' data from the HEIST (HEart surgery In AF and Supraventricular Tachycardia) registry. Between 2012 and 2020 we identified 4770 patients with pre-operative AF and multivessel coronary artery disease who underwent isolated CABG. We divided the cohort according to the completeness of the revascularization and used propensity score matching (PSM) to minimize differences between baseline characteristics. The primary endpoint was all-cause mortality.

Results

Median follow-up was 4.7 years [interquartile range (IQR) 2.3-6.9]. PSM resulted in 1,009 pairs of complete and incomplete revascularization. Number of distal anastomoses varied, accounting for 3.0 + -0.6 vs. 1.7 + -0.6, respectively. Although early (< 24 h) and 30-day post-operative mortalities were not statistically different between non-CR and CR patients [Odds Ratio (OR) and 95% Confidence Intervals (CIs): 1.34 (0.46-3.86); P = 0.593, Hazard Ratio (HR) and 95% CIs: 0.88 (0.59-1.32); P = 0.542, respectively] the long term mortality was nearly 20% lower in the CR cohort [HR (95% CIs) 0.83 (0.71-0.96); P = 0.011]. This benefit was sustained throughout subgroup analyses, yet most accentuated in low-risk patients (younger i.e., < 70 year old, with a EuroSCORE II < 2%, non-diabetic) and when off-pump CABG was performed.

Conclusion

Complete revascularization in patients with pre-operative AF is safe and associated with improved survival. Particular survival benefit with CR was observed in low-risk patients undergoing off-pump CABG.

Perioperative Oral Management Prevents Complications of Heart Valve Surgery

OBJECTIVES

The effect of perioperative oral management on the prevention of postoperative complications remains unclear in cardiac surgery. Exploratory factor analysis was performed to examine whether a lack of perioperative oral management was associated with postoperative complications of heart valve surgery.

MATERIALS AND METHODS

We retrospectively enrolled 365 patients who underwent heart valve surgery between April 2010 and March 2019. We extracted data on patient characteristics and set postoperative pneumonia and postoperative bloodstream infection as outcomes. A logistic regression analyses were performed to examine the effect of factors on the incidence of postoperative complications.

RESULTS

Significant risk factors for postoperative pneumonia included dialysis, long operative time, and long-term intubation. Similarly, risk factors for postoperative bloodstream infection were long-term intubation and lack of perioperative oral management. Subsequently, we identified the risk factors for long-term intubation, which were common to both complications, and found they were emergency status, combined valvular disease, long operative time, and lack of perioperative oral management.

CONCLUSIONS

We demonstrated that a lack of perioperative oral management could be a risk factor for postoperative bloodstream infection and long-term intubation in heart valve surgery. The results suggest that perioperative oral management is effective in preventing postoperative complications of heart valve surgery.

The Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations

BACKGROUND

The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures.

METHODS

Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

RESULTS

C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

CONCLUSIONS

New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.

Mixed-Valve Disease: Management of Patients with Aortic Stenosis and Mitral Regurgitation: Thresholds for Surgery Versus Percutaneous Therapies

Significant mitral regurgitation (MR), frequently seen in the presence of severe aortic stenosis (AS), results in an association that negatively affects prognosis and imposes particular challenges for both the assessment of the severity of valvular lesions and decisions regarding treatment allocation. This article reviews the available literature with regards to the assessment of MR and AS in the presence of both; surgical management and results in patients with concomitant AS and MR; the effect of MR on outcomes in patients undergoing transcatheter aortic valve replacement; the effect of transcatheter aortic valve replacement on MR severity; and percutaneous treatment for MR after transcatheter aortic valve implantation. The authors aim to provide assistance in the decision-making process to treat patients with either a higher-risk double-valve procedure or a simpler, but perhaps incomplete, single-valve option.

Routine preoperative doppler ultrasound examination of arterial system in patients undergoing cardiac surgery is beneficial: A retrospective study

Background:

Presence of peripheral vascular disease enhances surgical risk in cardiac surgical patients. Prior knowledge of peripheral arterial disease may help the physician make changes in the monitoring and cardiopulmonary bypass cannulation plans. It is claimed that the incidence of peripheral vascular disease in cardiac surgical patients ranges from 11 to 30%.

Aims:

This study was conducted to understand the characteristics of peripheral vascular disease and their implication on cardiac surgery.

Settings and Design:

This was a prospective study undertaken in a tertiary referral hospital.

Materials and Methods:

All adult patients who underwent cardiac surgery during the period of six months were included. A Doppler examination of the neck, upper limb, abdomen and lower limb was carried out by our inhouse radiologist. The incidence of peripheral vascular disease, the implication on invasive pressure monitoring site and cannulation for cardiopulmonary bypass or intraaortic balloon pump or extracorporeal membrane oxygenation were made note of.

Results:

During the said period, six hundred twenty eight patients underwent cardiac surgery, of whom five hundred and sixty-one patients who underwent CABG surgery. All these were subjected to Doppler examination. We observed peripheral arterial disease in 105 patients (20%). In general men suffered from PAD more often than women. Monitoring site of invasive arterial pressure, the choice of beating heart surgery, insertion of intraaortic balloon pump, femoral arterial route for cardiopulmonary bypass were some of the decision that were altered.

Conclusions:

Performing Doppler examination in cardiac surgical patients may yield important data that might prevent complications and support patient safety.

Combined Transcatheter Tricuspid and Pulmonary Valve Replacement

BACKGROUND

For patients with combined tricuspid and pulmonary valve disease, operative intervention carries high mortality risk. Published reports of combined transcatheter tricuspid and pulmonary valve replacement have been limited to single cases.

METHODS

A retrospective chart review was performed including all patients undergoing combined transcatheter tricuspid and pulmonary valve replacement at the Ahmanson/UCLA Adult Congenital Heart Disease Center.

RESULTS

Combined transcatheter tricuspid and pulmonary valve replacement was undertaken in five adult patients (median age: 46 years; range: 24-64 years). Three had congenital heart disease and two had carcinoid syndrome. Four patients had previous surgical tricuspid valve replacement and one had a surgical incomplete annuloplasty ring. Four patients had previous surgical pulmonary valve replacement and one had a right ventricle-to-pulmonary artery homograft conduit. Two patients underwent Medtronic Melody valve implantation in both tricuspid and pulmonary positions and three underwent Edwards Sapien S3 implantation in both tricuspid and pulmonary positions. Valve implantation was successful in all. Follow-up ranged from 0.9 to 3.0 years. One patient underwent redo transcatheter tricuspid valve replacement 12 months after the first transcatheter intervention for progressive regurgitation of a Melody valve. This patient died 2.5 years after combined valve placement of complications from refractory heart failure. The remaining patients were alive and free of valve reintervention at follow-up.

CONCLUSIONS

Combined transcatheter tricuspid and pulmonary valve replacement can be performed successfully, with an acceptable complication rate. This strategy is a feasible option for appropriately selected patients.

Contemporary Surgical Management of Atrial Fibrillation

Atrial fibrillation is a common arrhythmia which may cause symptoms that significantly impact quality of life and is associated with increased risk of stroke, heart failure, and sudden death. Over the past three decades many surgical techniques as well as catheter-bases procedures have been developed to treat atrial fibrillation. In this review we describe the indications, treatments, outcomes, surgical techniques, and technical advances reported in the literature.

Atrial fibrillation surgery with a focus on patients with reduced left ventricular function and heart failure

This review article aims to give an overview on the different surgical treatment options for atrial fibrillation It includes concomitant- as well as stand-alone surgical ablation therapy and outlines the main issues in patients with heart failure and reduced LVEF.

The Society of Thoracic Surgeons National Database 2019 Annual Report

The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety for cardiothoracic surgery. The STS National Database has 4 components, each focusing on a distinct discipline-Adult Cardiac Surgery, General Thoracic Surgery, Congenital Heart Surgery, and mechanical circulatory support with the STS Interagency Registry for Mechanical Circulatory Support (Intermacs)/Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides the fourth annual summary of the status of the STS National Database.

Clinical Prediction Models for Valvular Heart Disease

Background

While many clinical prediction models (CPMs) exist to guide valvular heart disease treatment decisions, the relative performance of these CPMs is largely unknown. We systematically describe the CPMs available for patients with valvular heart disease with specific attention to performance in external validations.

Methods and Results

A systematic review identified 49 CPMs for patients with valvular heart disease treated with surgery (n=34), percutaneous interventions (n=12), or no intervention (n=3). There were 204 external validations of these CPMs. Only 35 (71%) CPMs have been externally validated. Sixty‐five percent (n=133) of the external validations were performed on distantly related populations. There was substantial heterogeneity in model performance and a median percentage change in discrimination of −27.1% (interquartile range, −49.4%–−5.7%). Nearly two‐thirds of validations (n=129) demonstrate at least a 10% relative decline in discrimination. Discriminatory performance of EuroSCORE II and Society of Thoracic Surgeons (2009) models (accounting for 73% of external validations) varied widely: EuroSCORE II validation c‐statistic range 0.50 to 0.95; Society of Thoracic Surgeons (2009) Models validation c‐statistic range 0.50 to 0.86. These models performed well when tested on related populations (median related validation c‐statistics: EuroSCORE II, 0.82 [0.76, 0.85]; Society of Thoracic Surgeons [2009], 0.72 [0.67, 0.79]). There remain few (n=9) external validations of transcatheter aortic valve replacement CPMs.

Conclusions

Many CPMs for patients with valvular heart disease have never been externally validated and isolated external validations appear insufficient to assess the trustworthiness of predictions. For surgical valve interventions, there are existing predictive models that perform reasonably well on related populations. For transcatheter aortic valve replacement (CPMs additional external validations are needed to broadly understand the trustworthiness of predictions.

Surgical ablation of atrial fibrillation concomitant to coronary-artery bypass grafting provides cost-effective mortality reduction

BACKGROUND

Data on the longitudinal impact of surgical ablation (SA) for atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) remain limited. This study examined 2-year risk-adjusted mortality and total hospital costs in Medicare beneficiaries with AF requiring CABG with or without SA.

METHODS

CABG was performed in 3745 Medicare beneficiaries with AF in 2013, with concomitant SA in 17% (626 of 3745). Risk-adjusted mortality, morbidity, and cost during the first 2 postoperative years for patients with SA and those without SA were compared. A piecewise Cox proportional hazard model (0-90 days and 91-729 days) was used to risk-adjust mortality.

RESULTS

Compared with the no SA group, the SA group had lower rates of heart failure before surgery (31% vs 36%), chronic lung disease (27% vs 33%), renal failure (4% vs 7%), and urgent or emergent presentation (34% vs 49%) (all P < .05). Risk-adjusted index admission costs were higher with SA (rate ratio [RR], 1.11; P < .01), as were readmissions for AF (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.00-1.29; P = .04) and pacemaker/defibrillator implantation (HR, 1.37; 95%, 1.08-1.74; P = .01). Risk-adjusted inpatient days and inpatient costs were similar after 2 years (RR, 0.97; P = .31 and RR = 1.04; P = .17, respectively); however, the risk-adjusted hazard for late mortality (91-729 days) was significantly lower with SA (HR, 0.71; 95% CI, 0.52-0.97; P = .03).

CONCLUSIONS

In patients with AF requiring CABG, SA was associated with a 29% lower risk-adjusted hazard for late mortality. Index hospital costs were higher with SA, but total inpatient costs were not different in the 2 groups after 2 years. SA appears to be a cost-effective intervention to enhance late 2-year survival in patients with AF undergoing CABG.

Role of Hospital Volumes in Identifying Low-Performing and High-Performing Aortic and Mitral Valve Surgical Centers in the United States

Importance

Identifying high-performing surgical valve centers with the best surgical outcomes is challenging. Hospital surgical volume is a frequently used surrogate for outcomes. However, its ability to distinguish low-performing and high-performing hospitals remains unknown.

Objective

To examine the association of hospital procedure volume with hospital performance for aortic and mitral valve (MV) surgical procedures.

Design, Setting, and Participants

Within an all-payer nationally representative data set of inpatient hospitalizations, this study identified 682 unique hospitals performing surgical aortic valve replacement (SAVR) and MV replacement and repair with or without coronary artery bypass grafting (CABG) between 2007 and 2011. Procedural outcomes were further assessed for a 10-year period (2005-2014) to assess representativeness of study period.

Main Outcomes and Measures

In-hospital risk-standardized mortality rate (RSMR) calculated using hierarchical models and an empirical bayesian approach with volume-based shrinkage that allowed for reliability adjustment.

Results

At 682 US hospitals, 70 295 SAVR, 19 913 MV replacement, and 17 037 MV repair procedures were performed between 2007 and 2011, with a median annual volume of 43 (interquartile range [IQR], 23-76) SAVR, 13 (IQR, 6-22) MV replacement, and 9 (IQR, 4-19) MV repair procedures. Of 225 SAVR hospitals in the highest-volume tertile, 34.7% and 36.0% were in the highest-RSMR tertile for SAVR + CABG and isolated SAVR procedures, respectively, while 21.5% and 17.5% of the 228 SAVR hospitals in the lowest-volume tertile were in the lowest respective RSMR tertile. Similarly, 36.8% and 43.5% of hospitals in the highest tertile of volume for MV replacement and repair, respectively, were in the corresponding highest-RSMR tertile, and 17.4% and 11.2% of the low-volume hospitals were in the lowest-RSMR tertile for MV replacement and repair, respectively. There was limited correlation between outcomes for SAVR and MV procedures at an institution. If solely volume-based tertiles were used to categorize hospitals for quality, 44.7% of all valve hospitals would be misclassified (as either low performing or high performing) when assessing performance based on tertiles of RSMR.

Conclusions and Relevance

Hospital procedure volume alone frequently misclassifies hospital performance with regard to risk-standardized outcomes after aortic and MV surgical procedures. Valve surgery quality improvement endeavors should focus on a more comprehensive assessment that includes risk-adjusted outcomes rather than hospital volume alone.

Comparison of Two Major Perioperative Bleeding Scores for Cardiac Surgery Trials

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Research into major bleeding during cardiac surgery is challenging due to variability in how it is scored. Two consensus-based clinical scores for major bleeding: the Universal definition of perioperative bleeding and the European Coronary Artery Bypass Graft (E-CABG) bleeding severity grade, were compared in this substudy of the Transfusion Avoidance in Cardiac Surgery (TACS) trial.

Methods

As part of TACS, 7,402 patients underwent cardiac surgery at 12 hospitals from 2014 to 2015. We examined content validity by comparing scored items, construct validity by examining associations with redo and complex procedures, and criterion validity by examining 28-day in-hospital mortality risk across bleeding severity categories. Hierarchical logistic regression models were constructed that incorporated important predictors and categories of bleeding.

Results

E-CABG and Universal scores were correlated (Spearman ρ = 0.78, P &lt; 0.0001), but E-CABG classified 910 (12.4%) patients as having more severe bleeding, whereas the Universal score classified 1,729 (23.8%) as more severe. Higher E-CABG and Universal scores were observed in redo and complex procedures. Increasing E-CABG and Universal scores were associated with increased mortality in unadjusted and adjusted analyses. Regression model discrimination based on predictors of perioperative mortality increased with additional inclusion of the Universal score (c-statistic increase from 0.83 to 0.91) or E-CABG (c-statistic increase from 0.83 to 0.92). When other major postoperative complications were added to these models, the association between Universal or E-CABG bleeding with mortality remained.

Conclusions

Although each offers different advantages, both the Universal score and E-CABG performed well in the validity assessments, supporting their use as outcome measures in clinical trials.

Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: the Tufts experience

BACKGROUND

For over 50 years, surgical septal myectomy has been the preferred treatment for drug-refractory heart failure symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM). Over this time in the United States, the majority of myectomy operations have been performed in a small number of select referral centers.

METHODS

We have taken the opportunity to report results from the relatively new Tufts HCM Center and surgical program, incorporated 13 years ago, during which 507 myectomies (52±14 years of age; 56% male) were performed by one cardiothoracic surgeon, Dr. Hassan Rastegar.

RESULTS

Resting left ventricular (LV) outflow gradients were reduced from 56±42 mmHg preoperatively to 1.2±6.8 mmHg on most recent echocardiogram 2.0±2.5 years after surgery, and 94% of patients showed clinical improvement to NYHA functional class I or II. The first 200 myectomies were performed without mortality or major complications. Among all patients, 30-day mortality rate was 0.8%. Over follow-up of 3.2±2.8 years, 11 patients died (four due to HCM causes) with long-term survival after myectomy of 94% at 5 years (95% CI: 89-96%) and 91% at 10 years (95% CI: 84-95%), which did not differ from the age- and gender-matched general U.S. population (log-rank P=0.9).

CONCLUSIONS

This experience demonstrates that, with the appropriate support, new HCM surgical programs can provide patients successful relief of outflow obstruction, extended longevity and restored of quality of life.

Minimally invasive valve surgery in high-risk patients

The use of minimally, or less invasive, approaches to cardiac valve surgery has increased over the past decade. Because of its less traumatic nature, early studies in lower risk patients demonstrated the approach to be associated with an enhanced recovery, increased patient satisfaction, and good operative outcomes. With time, despite a steep learning curve, surgeons expanded this approach to perform more complex procedures, and include patients with more co-morbidity. The aim of this publication is to review the current literature involving the use of minimally invasive valve surgery (MIVS) in higher-risk patients.

Outcomes of minimally invasive double valve surgery

BACKGROUND

Double valve surgery is associated with an increased peri-operative morbidity and mortality. A less invasive right thoracotomy approach may be a viable alternative to median sternotomy surgery in these higher-risk patients.

METHODS

We retrospectively analyzed the baseline demographics, operative characteristics, and post-operative outcomes of patients who underwent minimally invasive double valve surgery between January 2009 and December 2011 at our institution.

RESULTS

The cohort consisted of 117 patients, of which 68 (58.1%) were female. The mean age was 73±11 years, and the mean left ventricular ejection fraction was 52±11%. There were 43 (36.8%) patients with a history of congestive heart failure, 45 (38.5%) with chronic obstructive pulmonary disease, and 5 (4.3%) had a history of chronic kidney disease. The patients underwent primary (90.6%) or re-operative (9.4%) double valve surgery, which consisted of 50 (42.7%) aortic valve replacement and mitral valve repair, 31 (26.5%) mitral and tricuspid valve repair, 18 (15.4%) aortic and mitral valve replacement, 17 (14.5%) mitral valve replacement with tricuspid valve repair, and 1 (0.9%) aortic valve replacement with tricuspid valve repair. Post-operatively, there were 40 (34.2%) cases of prolonged ventilation, 9 (7.7%) acute kidney injury, 6 (5.1%) re-operations for bleeding, 1 (0.9%) cerebrovascular accident, and 15 (12.8%) cases of atrial fibrillation. The mean total hospital length of stay was 12±12 days, with an in-hospital mortality of 2 (1.7%).

CONCLUSIONS

A minimally invasive right thoracotomy approach to primary or re-operative double valve surgery is feasible, may be utilized with acceptable peri-operative morbidity and mortality.

Aortic valve replacement in patients with a left ventricular ejection fraction ≤35% performed via a minimally invasive right thoracotomy

BACKGROUND

We evaluated the outcomes of patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35% who underwent minimally invasive aortic valve replacement (AVR), with or without concomitant mitral valve (MV) surgery.

METHODS

All minimally invasive AVR in patients with a left ventricular ejection fraction ≤35%, performed via a right thoracotomy for aortic stenosis or regurgitation between January 2009 and March 2013, were retrospectively evaluated. The operative characteristics, perioperative outcomes, and 30-day mortality were analyzed.

RESULTS

There were 75 patients identified: 51 who underwent isolated AVR, and 24 who had combined AVR plus MV surgery for moderate to severe mitral regurgitation. In patients undergoing MV surgery, there were 22 (91.7%) MV repairs [ring annuloplasty =7 (37.5%), transaortic edge-to-edge repair =15 (62.5%)], and 2 (8.3%) replacements. No patient required conversion to sternotomy for inadequate surgical field exposure. The median total mechanical ventilation time and intensive care unit length of stay were 14 (IQR, 8-20) and 42 hours (IQR, 26-93 hours) in the isolated AVR group, and 16.5 hours (IQR, 12-61.5 hours) and 95.5 hours (IQR, 43.5-159 hours) in the AVR plus MV surgery group, respectively. The most common post-operative complication was new-onset atrial fibrillation, which occurred in 15 (29.4%) isolated AVR and 4 (16.7%) AVR plus MV surgery patients. The median hospital length of stay and 30-day mortality was 7 days (IQR, 5-12 days) and 1 (2%) in the isolated AVR group, and 10.5 days (IQR, 5-21 days) and 1 (4.3%) for AVR plus MV surgery.

CONCLUSIONS

In patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35%, minimally invasive AVR can be performed, with or without concomitant MV surgery, with a low morbidity and mortality.

The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation

EXECUTIVE SUMMARY

Surgical ablation for atrial fibrillation (AF) can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant mitral operations to restore sinus rhythm. (Class I, Level A) Surgical ablation for AF can be performed without additional operative risk of mortality or major morbidity, and is recommended at the time of concomitant isolated aortic valve replacement, isolated coronary artery bypass graft surgery, and aortic valve replacement plus coronary artery bypass graft operations to restore sinus rhythm. (Class I, Level B nonrandomized) Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based therapy or both is reasonable as a primary stand-alone procedure, to restore sinus rhythm. (Class IIA, Level B randomized) Surgical ablation for symptomatic persistent or longstanding persistent AF in the absence of structural heart disease is reasonable, as a stand-alone procedure using the Cox-Maze III/IV lesion set compared with pulmonary vein isolation alone. (Class IIA, Level B nonrandomized) Surgical ablation for symptomatic AF in the setting of left atrial enlargement (≥4.5 cm) or more than moderate mitral regurgitation by pulmonary vein isolation alone is not recommended. (Class III no benefit, Level C expert opinion) It is reasonable to perform left atrial appendage excision or exclusion in conjunction with surgical ablation for AF for longitudinal thromboembolic morbidity prevention. (Class IIA, Level C limited data) At the time of concomitant cardiac operations in patients with AF, it is reasonable to surgically manage the left atrial appendage for longitudinal thromboembolic morbidity prevention. (Class IIA, Level C expert opinion) In the treatment of AF, multidisciplinary heart team assessment, treatment planning, and long-term follow-up can be useful and beneficial to optimize patient outcomes. (Class I, Level C expert opinion).