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Brown JA, Verghis NM, Yousef S, Serna-Gallegos D, Zhu J, Thoma F, Kaczorowski D, Chu D, Bonatti J, Yoon P, Phillippi J, Sultan I. Outcomes of Aortomitral Continuity Reconstruction During Concomitant Aortic and Mitral Valve Replacement. J Cardiothorac Vasc Anesth 2024; 38:905-910. [PMID: 38350743 DOI: 10.1053/j.jvca.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/16/2023] [Accepted: 01/10/2024] [Indexed: 02/15/2024]
Abstract
OBJECTIVES To describe outcomes of reconstruction of the aortomitral continuity (AMC) during concomitant aortic and mitral valve replacement (ie, the "Commando" procedure). DESIGN A retrospective study of consecutive cardiac surgeries from 2010 to 2022. SETTING At a single institution. PARTICIPANTS All patients undergoing double aortic and mitral valve replacement. INTERVENTIONS Patients were dichotomized by the performance (or not) of AMC reconstruction. MEASUREMENTS AND MAIN RESULTS A total of 331 patients underwent double-valve replacement, of whom 21 patients (6.3%) had a Commando procedure. The Commando group was more likely to have had a previous aortic valve replacement (AVR) or mitral valve replacement (MVR) (66.7% v 27.4%, p < 0.001), redo cardiac surgery (71.4% v 31.3%, p < 0.001), and emergent/salvage surgery (14.3% v 1.61%, p = 0.001), whereas surgery was more often performed for endocarditis in the Commando group (52.4% v 22.9%, p = 0.003). The Commando group had higher operative mortality (28.6% v 10.7%, p = 0.014), more prolonged ventilation (61.9% v 31.9%, p = 0.005), longer cardiopulmonary bypass time (312 ± 118 v 218 ± 85 minutes, p < 0.001), and longer ischemic time (252 ± 90 v 176 ± 66 minutes, p < 0.001). Despite increased short-term morbidity in the Commando group, Kaplan-Meier survival estimation showed no difference in long-term survival between each group (p = 0.386, log-rank). On multivariate Cox analysis, the Commando procedure was not associated with an increased hazard of death, compared to MVR + AVR (hazard ratio 1.29, 95% CI: 0.65-2.59, p = 0.496). CONCLUSIONS Although short-term postoperative morbidity and mortality were found to be higher for patients undergoing the Commando procedure, AMC reconstruction may be equally durable in the long term.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Nina M Verghis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - David Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Julie Phillippi
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Kakavand M, Stembal F, Chen L, Mahboubi R, Layoun H, Harb SC, Xiang F, Elgharably H, Soltesz EG, Bakaeen FG, Hodges K, Vargo PR, Rajeswaran J, Firth A, Blackstone EH, Gillinov M, Roselli EE, Svensson LG, Pettersson GB, Unai S, Koprivanac M, Johnston DR. Contemporary experience with the Commando procedure for anterior mitral anular calcification. JTCVS OPEN 2024; 18:12-30. [PMID: 38690415 PMCID: PMC11056448 DOI: 10.1016/j.xjon.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/22/2023] [Accepted: 10/10/2023] [Indexed: 05/02/2024]
Abstract
Objective Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.
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Affiliation(s)
- Mona Kakavand
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Filip Stembal
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lin Chen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rashed Mahboubi
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serge C. Harb
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G. Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R. Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Austin Firth
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B. Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Wu DM, Konstantinov IE, Zhu MZ, Ishigami S, Chowdhuri KR, Brizard CP, Buratto E. Surgery for paravalvular abscess in children. JTCVS OPEN 2023; 16:648-655. [PMID: 38204677 PMCID: PMC10775127 DOI: 10.1016/j.xjon.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/13/2023] [Accepted: 08/28/2023] [Indexed: 01/12/2024]
Abstract
Objective To investigate the outcomes of surgery in children with paravalvular abscess at our institution. Methods A retrospective review of all patients who underwent surgery for paravalvular abscess was performed. Results Between 1989 and 2020, 30 patients underwent surgery for paravalvular abscess, of whom 5 (16.7%) had an intracardiac fistula and 6 (20.0%) had a pseudoaneurysm. Aortic annulus abscesses were most common, occurring in 23 patients (76.7%). Aortic root replacement was performed in 17 patients (56.7%), root reconstruction was performed in 4 (13.3%), and reconstruction of the central fibrous body was required in 5 (16.7%). Postoperatively, 7 patients (23.3%) required extracorporeal membrane oxygenation (ECMO) support, and 1 patient (3.3%) required permanent pacemaker insertion. There were 6 early deaths, 5 of whom were on ECMO, and no late deaths, with a 15-year survival of 79.7% (95% confidence interval [CI], 60.2%-90.3%). Deaths were from sudden cardiac arrest resulting in brain death in 3 patients, inability to wean from ECMO due to severe cardiac dysfunction in 2 patients, and cerebral mycotic aneurysm and hemorrhage in 1 patient. Freedom from reoperation was 40.0% (95% CI, 17.0%-62.3%) at 15 years Reoperation due to recurrence was rare, occurring in only 2 patients (6.7%). Streptococcus pneumoniae (hazard ratio [HR], 9.2; 95% CI, 1.6-51.7) and preoperative shock (HR, 6.4; 95% CI, 1.3-32.0) were associated with mortality. Central fibrous body reconstruction was associated with reoperation (HR, 4.4; 95% CI, 1.2-16.1). Conclusions Although paravalvular abscess in children is associated with high early mortality, hospital survivors have good long-term survival. Reoperation is frequent, but is rarely due to recurrence of endocarditis.
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Affiliation(s)
- Damien M. Wu
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Igor E. Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia
| | - Michael Z.L. Zhu
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Shuta Ishigami
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Kuntal Roy Chowdhuri
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Christian P. Brizard
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia
| | - Edward Buratto
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
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