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OBJECTIVES: Medical care in low-income countries is often limited by inadequate resources, treatment facilities, and the necessary infrastructure for healthcare delivery. We hypothesized that the development of an independently functioning, internationally supported Kenyan cardiac surgical training program could address these issues through targeted investment. METHODS: A review was conducted of the programmatic structure and clinical outcomes from January 2008 to October 2021 at Tenwek Hospital, Bomet, Kenya. Program development phases included (1) cardiovascular care provided by 1 full-time US board-certified cardiothoracic surgeon; (2) short-term volunteer surgical teams from the United States and Canada; and (3) development of a cardiothoracic residency program based on the Society of Thoracic Surgeons training curriculum. Patient demographics and outcomes were analyzed throughout each phase of program development. RESULTS: A total of 817 cardiac procedures were performed during the study period, including 236 congenital (28.8%) and 581 adult (71.1%) procedures. Endemic rheumatic valvular heart disease predominated (581 patients, 62.3%). Local surgical team case volume grew over the study period, overtaking visiting team volume in 2019. Perioperative mortality was 2.1% and consistent between the visiting teams and the locally trained teams. Surgical training via a 3-year cardiothoracic residency is now in its fourth year, with the 2 graduates now retained as full-time teaching staff. CONCLUSIONS: Global health partnerships have the potential to address unmet needs in cardiac care within low- and middle-income countries. These data support the concept that acceptable clinical outcomes and consistent growth in volume can be achieved during the transition toward fully independent cardiac surgical care.

Extracorporeal membrane oxygenation (ECMO) has diverse applications. In the present report, we have described a case of tracheomalacia from a thoracic aortic aneurysm causing respiratory failure. Total arch replacement with reverse frozen elephant trunk grafting was performed. Perioperative ECMO support was accomplished with venopulmonary artery ECMO. This strategy allowed for preoperative oxygenation support, venous drainage during cardiopulmonary bypass, and postoperative support without cannula exchanges. Our patient required ECMO support for 12 days postoperatively. We have illustrated a unique case of acquired tracheomalacia but also an ECMO cannulation strategy allowing for preoperative oxygenation, seamless transition to cardiopulmonary bypass, and postoperative support.

BACKGROUND: Donor ethnicity is a prognosticator in organ transplant. However, the impact of donor/recipient race-matching is unclear. We hypothesized that there would be increased survival in donor-recipient race-matched organ recipients due to genetic and physiologic similarities. METHODS: The UNOS database from 1999-2018 was queried for all solid organ transplantations including heart, lung, liver, kidney, and pancreas transplants. Data was sorted by donor and recipient race into matched and unmatched categories for Caucasian, African-American, and Hispanic transplant recipients. After controlling for potential confounders via inverse propensity of treatment weighting, post-transplant patient and graft survival were compared between race matched and unmatched donor groups for each organ. RESULTS: Race-matched Caucasian recipients experienced 1-3% improvement in mortality across most timepoints in lung, liver, and pancreas transplants while Hispanics did not benefit. Matched African-American recipients experienced 4-6% improvement in patient and graft survival in liver transplant but had 7-9% worse survival rates at 5 years in lung and pancreas transplants. CONCLUSIONS: Race-matching does not influence patient outcomes enough to factor into organ transplant offers. African-American liver transplant recipients benefited the most. Matching was detrimental to African-American lung and pancreas transplant recipients indicating there may be other factors influencing the outcomes of these transplants.

A right ventricular assist device (RVAD) using a dual-lumen percutaneous cannula inserted through the right internal jugular vein (IJV) might improve weaning in patients with refractory right ventricular (RV) failure. However, the reported experience with this cannula is limited. We reviewed the records of all patients receiving RVAD support with this new dual-lumen cannula at our institution between April 2017 and February 2019. We recorded data on weaning, mortality, and device-specific complications. We compared outcomes among three subgroups based on the indications for RVAD support (postcardiotomy, cardiogenic shock, and primary respiratory failure) and against similar results in the literature. Mean (standard deviation [SD]) age of the 40 patients (29 men) was 53 (15.5) years. Indications for implantation were postcardiotomy support in 18 patients, cardiogenic shock in 12, and respiratory failure in 10. In all, 17 (94%) patients in the postcardiotomy group were weaned from RVAD support, five (42%) in the cardiogenic shock group, and seven (70%) in the respiratory failure group, overall higher than those reported in the literature (49% to 59%) for surgically placed RVADs. Whereas published in-hospital mortality rates range from 42% to 50% for surgically placed RVADs and from 41% to 50% for RVADs with percutaneous cannulas implanted through the right IJV, mortality was 11%, 58%, and 40% in our subgroups, respectively. There were no major device-related complications. This percutaneous dual-lumen cannula appears to be safe and effective for managing refractory RV failure, with improved weaning and mortality profile, and with limited device-specific adverse events.

Despite the widespread belief that donor organ availability varies around holidays and seasons, there is little empirical data supporting this long-held belief. Variations in donor heart availability may be of interest to patients and clinicians. The UNOS/OPTN registry was queried for all heart donations from October 1987 through March 2017. Daily heart donation rates were modeled nationally using Poisson regression including splines for year and day of the year. Seasonality was assessed using a likelihood ratio test for the spine terms for day of the year. The holiday effect was assessed using conditional logistic regression. Seasonal plots suggest a significant, although modest, increase in organ availability during the summer months, except for region 1. The regions with the highest amplitude were region 7 (peak: June 21, amplitude: 16.63%) and region 6 (peak: July 5, amplitude: 11.29%). There was no significant difference in the odds of heart donation when comparing holidays vs. non-holidays using national data (odds ratio [95% CI]: 1.01 [0.98, 1.03], P = 0.560) or any regional subsets. There was no observable correlation between donor heart availability and holidays. However, a significant seasonality effect was observed with higher donation rates occurring during warmer months.

We studied whether sustained hemodynamic support (>7 d) with the Impella 5.0 heart pump can be used as a bridge to clinical decisions in patients who present with cardiogenic shock, and whether such support can improve their outcomes. We retrospectively reviewed cases of patients who had Impella 5.0 support at our hospital from August 2017 through May 2019. Thirty-four patients (23 with cardiogenic shock and 11 with severely decompensated heart failure) underwent sustained support for a mean duration of 11.7 ± 9.3 days (range, ≤48 d). Of 29 patients (85.3%) who survived to next therapy, 15 were weaned from the Impella, 8 underwent durable left ventricular assist device placement, 4 were escalated to venoarterial extracorporeal membrane oxygenation support, and 2 underwent heart transplantation. The 30-day survival rate was 76.5% (26 of 34 patients). Only 2 patients had a major adverse event: one each had an ischemic stroke and flail mitral leaflet. None of the devices malfunctioned. Sustained hemodynamic support with the Impella 5.0 not only improved outcomes in patients who presented with cardiogenic shock, but also provided time for multidisciplinary evaluation of potential cardiac recovery, or the need for durable left ventricular assist device implantation or heart transplantation. Our study shows the value of using the Impella 5.0 as a bridge to clinical decisions.

Short-term extracorporeal membrane oxygenation is a useful adjunct to thoracic procedures. We report the cases of 2 middle-aged men who were supported with venovenous extracorporeal membrane oxygenation to facilitate tumor debulking and recanalization of the carina and mainstem bronchi. Neither patient had major complications or adverse events. These cases suggest that short-term extracorporeal membrane oxygenation is safe in patients undergoing complex resection or debulking of endobronchial lesions.

Patent foramen ovale (PFO) closure is indicated in cryptogenic stroke. Percutaneous PFO closure is both feasible and highly efficacious with low incidence of device-related complications. When complications occur, they are usually discovered within 6 weeks of device deployment. We describe the case of a partially embolised and fractured Gore Helex Septal Occluder device recognised nearly 9 years after placement requiring surgical explant.

Microaxial left ventricular assist devices (mLVADs) have traditionally been placed through a transfemoral or transaxillary arterial approach. Transfemoral access is restrictive, significantly limiting postoperative patient ambulation. Transaxillary placement is preferred but not feasible in a subset of patients due to small arterial diameter or tight angulation of the thoracic outlet. Transcarotid delivery has been utilized for other cardiovascular device deployment with good success; however, this approach has not been described for mLVAD support. We present a case series of transcarotid placement of mLVADs in cases where a transaxillary and transfemoral approach was not feasible. From May 2017 to April 2019, six patients in cardiogenic shock required mLVAD support achieved via a transcarotid approach. Technical success was achieved in all patients. One patient was directly weaned from mLVAD support and two patients died on mLVAD support. Escalation to venoarterial extracorporeal membrane oxygenation (VA-ECMO) was required for three patients, two of whom subsequently died. There were no bleeding or valvular complications related to device placement, and no obvious or known neurologic complications related to mLVAD support. Transcarotid placement of mLVADs expands the utility of these devices as an alternative to traditional support strategies or prohibitive arterial anatomy; however, further study is needed to determine its efficacy.

AIM The lungs-and particularly the alveolar-capillary membrane-may be sensitive to continuous flow (CF) and pulmonary pressure alterations in heart failure (HF). We aimed to investigate long-term effects of CF pumps on respiratory function. METHODS AND RESULTS We conducted a retrospective study of patients with end-stage HF at our institution. We analysed pulmonary function tests [e.g. forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1 )] and diffusing capacity of the lung for carbon monoxide (DLCO ) from before and after left ventricular assist device (LVAD) implantation and compared them with invasive haemodynamic studies. Of the 274 patients screened, final study analysis involved 44 patients with end-stage HF who had CF LVAD implantation between 1 February 2007 and 31 December 2015 at our institution. These patients [mean (standard deviation, SD) age, 50 (9) years; male sex, n = 33, 75%] received either the HeartMate II (Thoratec Corp.) pump (77%) or the HeartWare (HeartWare International Inc.) pump. The mean (SD) left ventricular ejection fraction was 21% (13%). At a median of 237 days post-LVAD implantation, we observed significant DLCO decrease (-23%) since pre-implantation (P

Background Small studies have reported superiority of sirolimus (SRL) over calcineurin inhibitor (CNI) in mitigating cardiac allograft vasculopathy (CAV) after heart transplantation (HT). However, data on the long-term effect on CAV progression and clinical outcomes are lacking. Objectives The aim of this study was to test the long-term safety and efficacy of conversion from CNI to SRL as maintenance therapy on CAV progression and outcomes after HT. Methods A cohort of 402 patients who underwent HT and were either treated with CNI alone (n = 134) or converted from CNI to SRL (n = 268) as primary immunosuppression was analyzed. CAV progression was assessed using serial coronary intravascular ultrasound during treatment with CNI (n = 99) and after conversion to SRL (n = 235) in patients who underwent at least 2 intravascular ultrasound studies. Results The progression in plaque volume (2.8 ± 2.3 mm3/mm vs. 0.46 ± 1.8 mm3/mm; p 2 years) after HT. Conclusions Early conversion to SRL is associated with attenuated CAV progression and with lower long-term mortality and fewer CAV-related events compared with continued CNI use.

OBJECTIVES Infective endocarditis (IE) remains a life-threatening disease, despite the improvement in diagnostic and therapeutic measures. We reviewed our outcomes for all adults who underwent surgery for endocarditis at our centre. METHODS Between January 1995 and December 2013, 801 patients [586 men (73%)] underwent surgery for IE. Mean age was 60 ± 14.7 years. Native endocarditis (NE) was present in 372 patients (46%), and 379 (47%) patients had active IE. The mean follow-up period was 4.6 ± 4.75 years (maximum 20 years). RESULTS Single-valve endocarditis was present in 551 (69%) patients (392 aortic and 159 mitral). Multivalve involvement was present in 250 (31%) patients. Preoperative stroke was present in 149 (19%) patients, while 62 (8%) patients were on dialysis prior to surgery. Valve repair was possible in 122 (15%) patients, while 679 (85%) patients underwent valve replacement. Mechanical valves were used in 312 (39%) patients. Aortic homografts were used in 84 (10%) patients. Early mortality occurred in 64 (8%) patients. Overall survival at 5, 10 and 20 years was 68%, 45% and 8.4%, respectively. Postoperative stroke occurred in 16 (2%) patients, while 59 (7%) patients required new dialysis postoperatively. Multivariate analysis revealed active IE (P = 0.002), preoperative dialysis (P = 0.007), previous coronary artery bypass grafting (P = 0.001), root abscess (P = 0.006) and tricuspid valve or multivalve involvement (P = 0.002) to be predictors of early mortality. The need for dialysis (P

OBJECTIVES Our goal was to compare the rates of in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) including death, stroke, myocardial infarction and repeat revascularization in patients with multivessel disease undergoing multiarterial (MultArt) coronary artery bypass grafting (CABG) with the left internal mammary artery/saphenous vein (LIMA/SV) CABG or percutaneous coronary intervention (PCI). METHODS From 1 January 1993 to 31 December 2009, 12 615 consecutive patients underwent isolated primary CABG (n = 6667) with LIMA/SV (n = 5712) or MultArt (n = 955) or were treated by PCI (n = 5948) with balloon angioplasty (n = 1020), bare metal stent (n = 3242), and drug-eluting stent (n = 1686). We excluded patients with acute myocardial infarction. We matched the CABG group with the 3 PCI subgroups, and the PCI group with the 2 CABG subgroups. Multivariable analyses were used to evaluate the impact of CABG versus PCI and their subgroups on early MACCE. RESULTS Unadjusted early MACCE were lower for MultArt (1.5%) than for LIMA/SV (4.5%, P

Owing to an inevitable degeneration of grafts over time, patients may require consideration for repeat coronary artery bypass graft (CABG) surgery. As our understanding of preoperative risks associated with redo CABG surgery is limited and availability of data is limited to historical cohorts, we sought to evaluate our contemporary 20-year experience with this challenging patient population.Between January 1993 and June 2014, 748 patients underwent redo CABG surgery at our institution. Median age at reoperation was 69 years (range, 36 to 88), and 644 (86%) were male. Median follow-up was 15.1 years and was 100% complete. Preoperatively, 191 patients (26%) had diabetes mellitus, 562 (75%) had hypertension, 206 (28%) had peripheral vascular disease with 121 (16%) having a history of cerebrovascular disease, and 459 (61%) had prior myocardial infarction. Number of prior CABG operations was 1 in 682 patients (91%), 2 in 62 patients (8%), and 3 in 4 patients (1%).All patients underwent isolated redo CABG surgery; all 748 (100%) procedures were performed using cardiopulmonary bypass, with median time on pump of 95 minutes (maximum, 378) and cross-clamp time of 48 minutes (maximum, 176). There were 47 early deaths (6%); early nonfatal morbidity included renal failure in 51 patients (7%), stroke in 15 (2%), and pneumonia in 22 (3%). Overall 1-, 5-, and 10-year survival was 89%, 77%, and 51%, respectively. Age (hazard ratio [HR] 1.74, p 0.001), diabetes (HR 1.51, p0.001), peripheral vascular disease (HR 1.51, p0.001), and end-stage renal disease with dialysis (HR 11.85, p0.001) were associated with increased long-term mortality, whereas higher left ventricular ejection fraction (per 10% increase) was protective (HR 0.78, p0.001).Redo CABG can be performed safely with low early and late morbidity and mortality. Important predictors of long-term mortality such as age, diabetes, renal disease, and peripheral vascular disease were identified and should guide the treatment strategy chosen for this challenging group of patients.

Background Historically the most common causes of pericarditis necessitating pericardiectomy are infection, radiation, idiopathic causes, and inflammation. More recently, there has been a rise in iatrogenic pericardial constriction, with most cases occurring after coronary artery bypass grafting (CABG). To date, there has been no large series evaluating the incidence, presentation, and effectiveness of surgical intervention. We review our 20-year experience managing this special subset of patients. Methods From January 1993 to December 2013, 938 patients underwent pericardiectomy at our institution. We identified 98 patients who underwent pericardiectomy after previous coronary bypass grafting. Demographic information was collected along with the indication for the procedure, technical aspects of the operation, early and late morbidity and mortality, and long-term New York Heart Association (NYHA) functional class. Median age at operation was 68 years (range, 38–81 years), and 91 of the patients (93%) were men. The indication for pericardiectomy was pericardial constriction in all patients. Median preoperative left ventricular ejection fraction was 60% (range, 30%–71%) and median NYHA functional class was III (91% were class III/IV). Results The surgical approach was median sternotomy in 81 patients (83%), left thoracotomy in 16 patients (16%), and a clamshell approach in 1 patient (1%). The extent of pericardial resection was radical in 61 patients (62%), subtotal in 27 patients (28%), and completion in 10 patients (10%). Cardiopulmonary bypass was used in 63 patients (64%) and aortic cross-clamping was used in 5 patients (5%). Concomitant coronary bypass grafting was performed in 10 patients (10%). Early mortality was seen in 3 of 98 patients (3%). The median duration of late follow-up was 3.2 years (maximum, 17.5 years), and overall 5- and 10-year survival was 62% and 41%, respectively. There were no multivariate predictors of worse outcome. The sole univariate predictor of lower overall survival was the use of cardiopulmonary bypass (hazard ratio, 1.96; 95% confidence interval, 1.03–3.7]; p = 0.04). NYHA functional class was I/II in 84% of patients at a median follow-up of 3.2 years. Conclusions The rate of early mortality for pericardiectomy after previous coronary bypass grafting is low, and the late adverse impact of cardiopulmonary bypass likely reflects increased severity of disease and technical complexity. Importantly, during late follow-up extending more than 17 years, the vast majority of patients demonstrated significant improvement in NYHA functional class.

Background Analyses of the HeartMate II left ventricular assist device are routinely performed after explant if returned to the manufacturer. Findings from manufacturer-reported pump analyses have not been correlated with pre-explant serum lactate dehydrogenase (LDH) values. Methods Between May 2004 and December 2014, 502 patients underwent primary HeartMate II implantation. Seventy pumps were explanted in 58 patients and returned to the manufacturer for pump analysis: 51 (73%) for suspected pump thrombosis, 12 (17%) for device-related infection, and 7 (13%) for percutaneous lead fracture. Median time from implant to explant was 12.4 months (range, 1 to 57 months). Results Pump thrombus was confirmed in 53 of 70 pumps (76%). Stratified by major clinical indications for explant of suspected pump thrombus or infection and lead fracture, the presence of pump thrombus was identified in 47 of 51 (92%) and 6 of 19 (32%), respectively. The median of 1) all LDH values, 2) maximum LDH values, and 3) interval change in LDH between 6 and 2 months before device explant were 1,061, 1,940, and −27 IU/L with thrombus present and 533, 504, and 13 IU/L in the absence of thrombus. Density estimation of LDH concentrations identified that a LDH value of 1,155 IU/L in the 6 months preceding pump thrombus had a 78% sensitivity and 90% specificity for findings of pump thrombus at the time of pump analysis. Conclusions Pre-explant LDH concentrations significantly correlated with findings on manufacture-performed pump analysis. These data validate LDH surveillance as an important clinical tool for identification of pump thrombus.

Reversal of pulmonary hypertension has been observed in patients during a bridge to transplant with a left ventricular assist device. Total artificial heart (TAH) implant prevents subsequent right heart catheterization. Consequently, controversy exists over whether the prosthetic right ventricle improves or exacerbates pulmonary hypertension. A pulmonary artery (PA) pressure monitor was placed in two patients undergoing TAH implant, as a bridge to transplant. One patient had pulmonary hypertension at implant; the other had normal pulmonary pressures. Daily measurements were taken of systolic, diastolic, and mean PA pressures throughout support. Patient 1 received successful transplant after TAH support of 91 days. Systolic/diastolic (mean) PA pressures steadily decreased from 55/39 (28) mm Hg at implant to 29/18 (7) mm Hg currently. Patient 2 received support for 101 days before death due to abdominal ischemic complications. Pulmonary arterial pressures stayed consistent throughout this period, from 26/17 (20) mm Hg at implant to 23/13 (17) mm Hg at the time of death. These findings suggest that an implantable PA pressure monitor may be useful in optimizing hemodynamics and planning appropriate timing of transplant with TAH support.

The L-type calcium channel (LTCC) is one of the major ion channels that are known to be associated with the electrical remodeling of atrial fibrillation (AF). In AF, there is significant downregulation of the LTCC, but the underlying mechanism for such downregulation is not clear. We have previously reported that microRNA-499 (miR-499) is significantly upregulated in patients with permanent AF and that KCNN3, the gene that encodes the small-conductance calcium-activated potassium channel 3 (SK3), is a target of miR-499. We found that CACNB2, an important subunit of the LTCC, is also a target of miR-499. We hypothesize that miR-499 plays an important role in AF electrical remodeling by regulating the expression of CACNB2 and the LTCC. In atrial tissue from patients with permanent AF, CACNB2 was significantly downregulated by 67% (n = 4, p, Highlights • LTCC is downregulated with electrical remodeling of atrial fibrillation. • MiR-499 is increased and CACNB2 is reduced in atria from patients with atrial fibrillation. • MiR-499 binds to the 3′UTR of CACNB2 and inhibits its protein expression. • Downregulation of CACNB2 results in the downregulation of LTCC pore-forming subunit. • MiR-499 contributes to the electrical remodeling of AF through regulation of CACNB2.

Outcome after pericardiectomy depends on many factors, but no large study has provided clarity on the effects of patient variables or cause of pericarditis on patient survival. We report early and late results from a 20-year experience with isolated pericardiectomy.From January 1993 to December 2013, 938 patients underwent pericardiectomy at our institution. In order to establish a homogeneous population to analyze the impact of pericardiectomy, we excluded patients with prior chest radiation, malignancy, and concomitant valvular or coronary procedures. We identified a cohort of 521 who underwent isolated pericardiectomy; of these, 513 patients gave consent for research and comprise the cohort for this analysis; median age at operation was 57 years (range, 18-84 years) and 363 (71%) were men. Indications for pericardiectomy were effusive/chronic relapsing pericarditis in 158 (31%) and pericardial constriction in 355 (69%). Prior coronary artery bypass grafting had been performed in 84 patients (14%). Median preoperative left ventricular ejection fraction was 60% (range, 24%-80%), and 77% of patients were in New York Heart Association (NYHA) functional class III/IV.Surgical approach was median sternotomy in 412 (80%), left thoracotomy in 71 (14%), and clamshell in 30 (5%). Extent of pericardial resection was radical in 414 (81%), subtotal in 71 (14%), and completion in 28 (5%). Cardiopulmonary bypass was used in 205 (40%). Overall mortality was 12/513 (2.3%); 3/158 (1.9%) for the effusive/chronic relapsing group versus 9/355 (2.5%) for the constriction group (P = .65). In the absence of multivariate predictors, which could not be identified, univariate predictors associated with increased risk of early death included lower left ventricular ejection fraction (hazard ratio [HR], 1.09; P = .03) and preoperative renal insufficiency (HR, 9.9; P .001). Median duration of follow-up was 29 months (maximum 20.5 years) and overall 5-, 10-, and 15-year survival was 80%, 60%, and 38%, respectively. Overall survival according to surgical indication was higher in the effusive/chronic relapsing group when compared with the constriction cohort (P .001). Independent predictors associated with increased risk of overall mortality identified on multivariate analysis included older age (HR, 1.05; 95% confidence interval [CI], [1.03, 1.07]; P .001), congestive heart failure (HR, 1.49; 95% CI, [1.03, 2.2]; P = .02), diabetes (HR, 1.83; 95% CI, [1.2, 2.7]; P = .004), completion pericardiectomy (HR, 2.4; 95% CI, [1.2, 4.7]; P = .01), and chronic obstructive pulmonary disease (HR, 2.45; 95% CI, [1.5, 3.9]; P = .004). During the follow-up period, 80% of patients were free from NYHA functional class III/IV symptoms at 5 years and 78% at 10 years.Whereas early mortality after isolated pericardiectomy is low irrespective of the indication for surgery, late follow-up demonstrates better outcomes after pericardiectomy for effusive/chronic relapsing pericarditis compared with pericardial constriction. Importantly, the majority of patients were free from significant heart failure symptoms during follow-up.

The gold standard for noninvasive blood pressure (BP) measurement, the Doppler technique, does not provide systolic blood pressure (SBP) and diastolic blood pressure (DBP) and may limit therapy outcomes. To improve patient care, we tested specifically designed experimental BP (ExpBP) monitor and the Doppler technique by comparing noninvasive measures to the intraarterial (I-A) BP in 31 patients with end-stage heart failure (4 females) 2.6 ± 3.4 days post-LVAD implantation (20 HeartMate II and 11 HeartWare). Bland-Altman plots revealed that the ExpBP monitor overestimated mean arterial pressure (MAP) by 1.2 (4.8) mm Hg (mean difference [standard deviation]), whereas the Doppler by 6.7 (5.8) mm Hg. The ExpBP SBP was overestimated by 0.8 (6.1) mm Hg and DBP by 1.9 (5.3) mm Hg compared with the respective I-A pressures. Both techniques achieved similar measurement reliability. In the measurement "success rate" expressed as a frequency (percent) of readable BP values per measurement attempts, Doppler accomplished 100% vs. 97%, 97%, and 94% of successful detections of MAP, SBP, and DBP provided by the ExpBP monitor. The ExpBP monitor demonstrated higher accuracy in the MAP assessment than the Doppler in addition to providing SBP and DBP in majority of subjects. Improved BP control may help to mitigate related neurologic adverse event rates.

Background: The FOXO3a (forkhead box O3a)-BNIP3 (B-cell lymphoma 2/adenovirus E1B 19kDa interacting protein 3) pathway modulates mitochondrial dynamics and function and contributes to myocardial remodeling in rodent models of heart failure. We sought to investigate the expression of this pathway along with the expression of mitochondrial biogenesis (PGC-1α [peroxisome proliferator-activated receptor-γ coactivator-1α]), dynamics (DRP-1 [dynamin-related protein 1], OPA-1 [optic atrophy 1], and MFN 2 [mitofusin 2]), and oxidative phosphorylation (citrate synthase and electron transport chain complexes) markers and COX IV (cytochrome C oxidase) activity in myocardium from patients with valvular or ischemic heart disease and heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Methods and Results: Subepicardial left ventricular biopsies (10×1×1 mm 3 ) were obtained at aortic valve replacement (HFpEF AVR , n=5; and HFrEF AVR , n=4), coronary artery bypass grafting (HFpEF CABG , n=5; and HFrEF CABG , n=5), or left ventricular assist device implantation (HFrEF LVAD , n=4). Subepicardial biopsies from patients with normal left ventricular function (n=2) and from donor hearts (n=3) served as controls (normal). Relative to normal, mitochondrial fragmentation and cristae destruction were evident, and mitochondrial area was decreased in HFpEF; 1.00±0.09 versus 0.71±0.08; P =0.016. These mitochondrial morphological changes were more pronounced in HFrEF (0.54±0.06); P =0.002 HFpEF versus HFrEF. BNIP3 (monomer+dimer) expression was increased in HFpEF (3.99±2.44) and in HFrEF (5.19±1.70) relative to normal; P =0.004 and P P =0.001 and 0.004, respectively. The HFrEF group uniquely showed increase in DRP-1 expression (1.94±0.38) and decreases in PGC-1α expression (0.61±0.07) and COX IV activity (0.70±0.10) relative to normal; P =0.013, P P Conclusions: These findings in human myocardium confirm studies in rodents where contractile dysfunction is associated with activation of the FOXO3a-BNIP3 pathway and altered mitochondrial dynamics, biogenesis, and function.

Midterm outcomes are unknown for patients undergoing aortic valve replacement (AVR) with a Mitroflow bovine pericardial prosthesis (Sorin Group, Inc) and without anticalcification treatment. Recent reports warn of early senescence in younger adults.From January 2004 through December 2011, 1,003 adults underwent Mitroflow AVR. The mean follow-up time was 25.0 (standard deviation [20.6]) months (total, 2,060 patient-years; maximum, 9 years). The patients were stratified for analysis according to age at implantation: group A,60 years (n = 63, 6.3%); group B, 60-69 years (n = 173, 17.2%); group C, 70-79 years (n = 432, 43.1%); and group D, 80 years or older (n = 335, 33.4%).The mean age was 74.8 years (SD 9.8), and 609 patients (60.7%) were men. Aortic valve stenosis was present in 912 patients (90.9%), and 113 (11.3%) had severe aortic regurgitation. There were 27 (2.7%) early deaths, 15 of 431 (3.5%) underwent concomitant coronary artery bypass grafting while 12 of 572 (2.1%) did not (p = 0.18), and 151 patients (15.1%) died during follow-up. Nineteen AVRs (1.9%) required re-replacement through August 2013; 12 (63.2%) were associated with structural valve deterioration. The overall rates of freedom from valve-related reoperation at 3 and 5 years were 98.3% and 93.8%, respectively. Group A had the greatest number of reoperations (6/63; p0.001). The overall survival rates at 1 and 5 years were 91.2% and 67.3%, respectively. Independent predictors of mortality were poorer New York Heart Association functional class (hazard ratio [HR], 2.1; p0.001), atrial fibrillation (HR, 1.8; p = 0.002), and prior cardiac operation (HR, 1.8; p = 0.003).Midterm follow-up shows acceptable hemodynamic performance of the Mitroflow biologic aortic valve prosthesis in selected patients 60 years old and older. Ongoing follow-up will be necessary to understand long-term performance and outcomes.

Background The risk of device-related adverse events leading to death is abundant and ever-present after left ventricular assist device (VAD) implantation. Very few data specifically examine the causes of death related to length of time after VAD implantation. Methods Between October 2004 and February 2013, 493 patients (395 male, 80%) underwent primary continuous-flow VAD implantation at our institutions. The median age at implantation was 60 years (range, 18–79 years), and 301 patients (62%) underwent bridge to transplantation. Results Follow-up was available for all patients (median, 13 months) for a total of 717 patient-years of support. There were 132 deaths during follow-up (median, 8 months; early, 5.5 years) after VAD implantation. The patients were grouped according to temporal occurrence of deaths: (1) early (30-day or index hospitalization) in 34 of 132 patients (26%), (2) between hospital dismissal and 6 months in 29 of 132 patients (22%), (3) 6 months to 1 year in 14 of 132 patients (11%), and (4) after 1 year in 55 of 132 patients (42%). The causes of death (%) at each time period are presented; the most common early cause was right ventricular failure/multisystem organ failure in 18 of 34 patients (61%); from dismissal to 6 months, and 6 months to 1 year, cerebral hemorrhage in 6 of 29 patients (21%) and 4 of 14 patients (29%), respectively; after 1 year, cerebral hemorrhage in 12 of 55 patients (22%) and right ventricular failure/multisystem organ failure in 11 of 55 patients (20%). Conclusions The causes of death vary according to time after VAD implantation. Understanding the temporal relationship of causes of mortality after VAD implantation is critical to the identification of varying specific risks in an effort to avoid morbidity, which may ultimately detract from a durable VAD outcome.

Aim The lungs—and particularly the alveolar‐capillary membrane—may be sensitive to continuous flow (CF) and pulmonary pressure alterations in heart failure (HF). We aimed to investigate long‐term effects of CF pumps on respiratory function. Methods and results We conducted a retrospective study of patients with end‐stage HF at our institution. We analysed pulmonary function tests [e.g. forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)] and diffusing capacity of the lung for carbon monoxide (D LCO) from before and after left ventricular assist device (LVAD) implantation and compared them with invasive haemodynamic studies. Of the 274 patients screened, final study analysis involved 44 patients with end‐stage HF who had CF LVAD implantation between 1 February 2007 and 31 December 2015 at our institution. These patients [mean (standard deviation, SD) age, 50 (9) years; male sex, n = 33, 75%] received either the HeartMate II (Thoratec Corp.) pump (77%) or the HeartWare (HeartWare International Inc.) pump. The mean (SD) left ventricular ejection fraction was 21% (13%). At a median of 237 days post‐LVAD implantation, we observed significant D LCO decrease (−23%) since pre‐implantation (P

Background Diabetes mellitus (DM) is a risk factor for morbidity and mortality in patients with heart failure. The effect of DM on post–left ventricular assist device (LVAD) implantation outcomes is unclear. This study sought to investigate whether patients with DM had worse outcomes than patients without DM after LVAD implantation and whether LVAD support resulted in a better control of DM. Methods and Results We retrospectively reviewed 341 consecutive adults who underwent implantation of LVAD from 2007 to 2016. Patient characteristics and adverse events were studied and compared between patients with and without DM. One hundred thirty-one patients (38%) had DM. Compared with patients without DM, those with DM had higher rates of ischemic cardiomyopathy, LVAD implantation as destination therapy, and increased baseline body mass index. In a proportional hazards (Cox) model with adjustment for relevant covariates and median follow-up of 16.1 months, DM was associated with increased risk of all-cause mortality (hazard ratio, 1.73; 95% confidence interval: 1.18–2.53; P =0.005) and increased risk of nonfatal LVAD-related complications, including a composite of stroke, pump thrombosis, and device infection (hazard ratio, 2.1; 95% confidence interval: 1.35–3.18; P =0.001). Preoperative hemoglobin A1c was not significantly associated with mortality or adverse events among patients with DM. LVAD implantation resulted in a remarkable decrease in hemoglobin A1c levels (7.4±1.9 pre-LVAD versus 6.0±1.5 and 6.3±1.4 after 3 and 12 months post-LVAD, respectively; P Conclusions DM is associated with increased rates of all-cause mortality and major adverse events despite favorable glycemic control after LVAD implantation.

Although improvement in cardiac output and hemodynamic parameters is routinely demonstrated in patients implanted with continuous-flow left ventricular assist devices (CF-LVADs), improvement in exercise capacity is inconsistently seen. Our purpose was to determine whether native cardiac factors, LVAD factors, or comorbid factors were associated with lack of improvement. Review of all patients undergoing preimplant cardiopulmonary exercise testing (CPET) and CPET on LVAD therapy at one institution was performed between 2007 and 2014 (n = 49). Comprehensive assessment of echocardiographic parameters, right heart catheterization data, medications, and comorbid illness was undertaken. There was no mean improvement in peak oxygen consumption (VO2; 11.8-12.4 ml/kg/min; p = 0.26), although exercise time (5.1 [46% predicted] to 5.8 min [56% predicted]; p = 0.02) and nadir of the ratio of minute ventilation to carbon dioxide production slope (VE/VCO2; 39-36; p = 0.001) improved. Factors most strongly associated with improvement in VO2 were Heartmate II pulsatility index (PI; R = 0.48; p = 0.001), power (R = -0.40; p = 0.009), pump flow (R = -0.40; p = 0.008), and pump speed (R = -0.32; p = 0.04). Peak heart rate (HR) was also associated with improvement in VO2 (R = 0.41; p = 0.004). Left ventricular ejection fraction (LVEF; R = 0.004; p = 0.77), right ventricular (RV) function (R = 0.22; p = 0.28), and aortic valve opening (R = 0.20; p = 0.57) were not associated with improvement in VO2. Our data suggest that less reliance on LVAD support was modestly associated with improvement in exercise capacity. Further studies should seek to determine the optimal level of device support prospectively in relation to exercise capacity.

We sought to identify the trends in bilateral internal thoracic artery use and determine the degree to which the survival advantage of bilateral internal thoracic artery revascularization persists among perceived "high-risk" patients, compared with the use of left internal thoracic artery alone.A retrospective review was conducted of patients who underwent isolated coronary artery bypass grafting for multivessel coronary artery disease at the Mayo Clinic between January 2000 and December 2015. Propensity score matching was performed between patients with bilateral internal thoracic artery and left internal thoracic artery alone grafts (1011 matched pairs). Effect of bilateral internal thoracic artery use on survival in "high-risk" patients (ejection fraction40%, body mass index ≥30, age ≥70 years, diabetes, chronic lung disease, cerebrovascular accident) was evaluated.A total of 6468 isolated coronary artery bypass grafts were performed (5431 using left internal thoracic artery alone, 1037 using bilateral internal thoracic artery). There was an increasing trend in bilateral internal thoracic artery use (P value for linear trend = .005), with the percentage of coronary artery bypass grafting cases with bilateral internal thoracic artery doubling over the last 4 years (13% in 2012 to 27% in 2015). Propensity-matched comparisons showed a survival advantage for bilateral internal thoracic artery (hazard ratio, 0.81; 95% confidence interval, 0.66-0.99; P = .043). Risk of deep sternal wound infection, although higher in the bilateral internal thoracic artery group, was not significant (1.2% vs 0.5%; P = .088). None of the "high-risk" subsets of patients showed an adverse effect of bilateral internal thoracic artery on survival.Bilateral internal thoracic artery use in coronary artery bypass grafting is increasing over time. There is a consistent survival benefit with bilateral internal thoracic artery use, extending to patients with higher-risk comorbidities, suggesting the need for further expansion in use of this technique.

ObjectiveThe study objective was to determine whether the new-generation Trifecta (St Jude Medical Inc, St Paul, Minn) bovine aortic valve bioprosthesis, which is designed for supra-annular positioning, produces early postoperative hemodynamic results comparable to or better than those of the Mitroflow (Sorin Group, Milan, Italy) or Perimount Magna (Edwards Lifesciences Corp, Irvine, Calif) bovine aortic valve bioprostheses.MethodsWe retrospectively reviewed the medical records of patients who underwent aortic valve replacement with a Trifecta, Mitroflow, or Perimount Magna bovine pericardial prosthesis at Mayo Clinic between June 2007 and December 2012 and analyzed early postoperative hemodynamic performance by Doppler echocardiography.ResultsA total of 1436 patients underwent aortic valve replacement (Trifecta in 196, Mitroflow in 1135, Perimount Magna in 105). Preoperative characteristics and early clinical outcomes were similar among the 3 valve groups. The average mean gradients were lower and valve areas were greater with the Trifecta valves. For the Trifecta, Mitroflow, and Perimount Magna valves, the average mean gradient was 11.4 mm Hg, 16.9 mm Hg, and 14.1 mm Hg, respectively; the effective orifice area was 2.22 cm2, 1.85 cm2, and 2.09 cm2, respectively; and the indexed effective orifice area was 1.14 cm2/m2, 0.96 cm2/m2, and 1.07 cm2/m2, respectively (all P

ObjectivesTo study the determinants of functional tricuspid regurgitation (TR) progression after surgical correction of mitral regurgitation, including the influence of mitral valve (MV) repair (MVr) versus replacement (MVR) for degenerative mitral regurgitation.MethodsFrom January 1995 to January 2006, 747 adults with MV prolapse underwent isolated MVr (n = 683) or MVR (n = 64; mechanical in 32). The mean age was 60.8 years, and 491 were men (66.0%). Moderate preoperative functional TR was present in 115 (15.4%). The MVR group had a greater likelihood of New York Heart Association class III or IV (75.0% vs 34.4%, P 5 years (6.1% vs 6.5%; P = .93). The univariate predictors of severe TR after 5 years were older age (hazard ratio [HR], 1.1; P = .011), female gender (HR, 6.86; P = .005), higher pulmonary artery pressure (HR, 1.05; P = .022), and larger left atrial size (HR, 2.11; P = .035). Two patients (0.26%) who had undergone initial MVr required reoperation for late functional TR. Another 2 patients had had the tricuspid valve addressed concurrent with reoperation for MVr failure. No tricuspid reoperations were required in the MVR group.ConclusionsThe risk of TR progression was low after MVr or MVR for MV prolapse. Timely MV surgery before the development of left atrial dilatation or pulmonary hypertension could further decrease the risk of TR progression during follow-up.

We conducted a metaanalysis comparing early and midterm cardiovascular adverse events associated with minimally invasive direct coronary artery bypass graft surgery (MIDCABG) and percutaneous coronary intervention (PCI), with a focus on drug-eluting stents (DES).A systematic literature review (MEDLINE, EMBASE, Scopus, and so forth) yielded 12 studies (7 randomized controlled trials; 5 observational) pooling more than 2,000 patients. A random effect, inverse variance metaanalysis was conducted, and a subgroup analysis of the PCI-DES cohort was performed. Events were compared as risk ratios using a 95% confidence interval (CI). Heterogeneity of results was evaluated by Eggers I(2) test. Results are presented as early (0 to 1 year) and midterm (2 to 5 years).Midterm mortality in the PCI and MIDCABG groups (3.6% and 2.6%, respectively) was comparable (1.24, 95% CI: 0.66 to 2.33; p = 0.5; I(2) = 0%). Risk of early restenosis was lower in the MIDCABG cohort compared with PCI (0.40, 95% CI: 0.16 to 0.99; p = 0.05; I(2) = 57%). Although the early risk of recurrence of angina was comparable, over time it was 61% (43% to 74%) lower for MIDCABG patients (p0.001). Midterm results on analysis of the entire cohort demonstrated an increased risk for target vessel reinterventions (3.84, 95% CI: 2.7 to 5.5; p0.001) in the PCI cohort. Subgroup analysis revealed that the PCI-DES cohort (4 studies; 456 patients) had a higher risk of recurrent angina (risk ratio 3.4, 95% CI: 1.9 to 6.2; p0.001; I(2) = 0%) and target vessel reinterventions (risk ratio 4.16, 95% CI: 2.7 to 6.6; p 0.001; I(2) = 0%) at midterm follow-up (2 to 5 years).Survival rates are comparable after either MIDCABG or PCI for proximal LAD disease. However, even the use of DES was associated with significantly higher rates of angina recurrence and the need for target vessel reintervention as compared with MIDCABG.

This study evaluated preoperative balloon aortic valvuloplasty (BAV) as a technique to decrease aortic valve replacement (AVR) risk in patients who have severe symptomatic aortic valve stenosis with substantial comorbidity. We report the outcomes of 18 high-risk patients who received BAV within 180 days before AVR from November 1993 through December 2011. Their median age was 78 years (range, 51–93 yr), and there were 11 men (61%). The pre-BAV median calculated Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) was 18.3% (range, 9.4%–50.7%). Preoperative left ventricular ejection fraction measured a median of 0.23 (range, 0.05–0.68), and the median aortic valve area index was 0.4 cm2/m2 (range, 0.2–0.7 cm2/m2). The median interval from BAV to AVR was 28 days (range, 1–155 d). There were no strokes or deaths after BAV; however, 4 patients (22%) required mechanical circulatory support, 3 (17%) required femoral artery operation, and 1 (6%) developed severe aortic valve regurgitation. After BAV, the median STS PROM fell to 9.1% (range, 2.6%–25.7%) (compared with pre-BAV, P Staged BAV substantially reduces the operative risk associated with AVR in selected patients.

Background Aortopathy associated with bicuspid aortic valve commonly involves the ascending aorta above the sinotubular ridge, but it may also affect sinus portions of the aorta. In some persons, the enlarged portion of the aortic root is limited to the noncoronary sinus. In such patients, we have spared the remaining portions of the aortic root by replacing the ascending aorta with a polyethylene terephthalate fiber (Dacron) graft and a tongue-shaped extension of the graft, thereby replacing the noncoronary sinus. In the present study, we evaluated late outcomes of this procedure, with specific attention to the fate of aortic tissue in the remaining sinuses. Methods We reviewed the medical records of 1,756 patients with repair of ascending aortic aneurysms at Mayo Clinic from 1993 through 2012. Among the patients, 631 (35.9%) had bicuspid aortic valve, and in 79 (4.5%) of the patients, the noncoronary sinus was replaced along with the ascending aorta. Results Associated aortic valve operations were performed in 70 patients; 15 had repair and 55 had aortic valve replacement. No early death occurred, but 3 patients died late after operation (5-year survival, 99%). There were 3 late reoperations, all because of native or prosthetic valve problems. Importantly, no instances occurred of aneurysm formation or aortic dissection related to the remaining aorta in the left and right aortic sinuses. Conclusions In patients with bicuspid aortic valve and aortic root enlargement related mainly to enlargement of the noncoronary sinus, limited replacement of the noncoronary sinus and ascending aorta is a safe and simple procedure that is durable in midterm follow-up.

Purpose Surgical bleeding in the immediate post-operative period presents a frequent challenge in the management of LVAD recipients. We hypothesized that implementing an aggressive approach to surgical hemostasis would reduce the rate of early mortality. Methods We conducted a single-center retrospective review of 78 patients who underwent LVAD implantation between 9/13/11 and 8/24/17. Logistic regressions were utilized to estimate the odds ratio for RVAD requirement and in-hospital mortality based on risk factors of six-hour chest tube output and return to operating room for bleeding. Chest tube output of greater than 600 cc in the first six hours was considered to be significant. Results When comparing chest tube outputs in the first six hours, there were no significant differences in age, gender, heart failure etiology, or device type in patients with >600 cc and those with lower outputs. Greater than 600 cc chest tube output in the first six hours was an independent predictor for RVAD requirement (15.2% vs. 2.3%, p=0.04) and in-hospital mortality (24.2% vs. 4.7%, p=0.012) than those with lower outputs. Patients who returned to the operating room for bleeding complications experienced a similar in-hospital mortality rate (17.6% vs. 9.3%, p=0.28) but had a higher RVAD requirement (14.7% vs. 2.3%, p=0.04). Multivariate analysis showed a statistical significance for in-patient mortality in patients with chest tube output >600 cc in the first 6 hours (p = 0.013). There was a close correlation between the amount of chest tube output during the first six hours and the risk of in-hospital mortality ( Figure 2 ). Conclusion Minimizing the degree of post-operative bleeding after LVAD surgery may result in a reduced rate of right ventricular failure and in-hospital mortality. These findings suggest that efforts should be undertaken to identify surgical strategies for achieving improved hemostasis at the time of implantation.

Because no series has specifically analyzed the impact of preoperative atrial fibrillation (AF) on patients already at higher risk of thromboembolism after implantation of a left ventricular assist device (LVAD), we review our experience with these patients.Between July 2003 and September 2011, 389 patients (308 male) underwent implantation of a continuous flow LVAD at University of Michigan Hospital and Mayo Clinic. Median age at implant was 60 years (range, 18 to 79 years). Preoperative AF was present in 120 patients (31%). Outcomes were analyzed for the association of preoperative AF and postoperative thromboembolic (TE) events defined as stroke, transient ischemic attack, hemolysis, or pump thrombosis. Thromboembolic events occurring within the first 30 days were not counted.One hundred thirty-eight TEs events occurred in 97/389 patients (25%) for an event rate of 0.31 TE events/patient-years of support. Freedom from a TE event in patients with preoperative AF was 62% at 1 year and 46% at 2 years compared with 79% and 72% at 1 and 2 years, respectively, in patients without preoperative AF (p 0.001). Median survival was 10 months (maximum 7.2 years, total 439 patient-years). Preoperative AF did not decrease late survival at 1 and 2 years after LVAD implant (preop AF: 85% and 70% versus no preop AF: 82% and 70%, respectively; p = 0.55).Patients with preoperative AF have a lower freedom from TE events after LVAD implant. While overall late survival was not significantly reduced in these patients, refinement in anticoagulation strategies after VAD implant may be required.

Advances in mechanical circulatory support have been critical in bridging patients awaiting heart transplantation. In addition, improvement in device durability has enabled left ventricular assist device therapy to be applied as destination therapy in those not felt to be transplant candidate. Because of the increasing complexity of patients, there continues to be a need for alternative strategies for device implantation to bridge high-risk patients awaiting heart transplantation, wherein the risks of numerous previous sternotomies may be prohibitive. We present a unique technique for placement of the HeartWare ventricular assist device via left anterior thoracotomy to the descending aorta in a patient awaiting heart transplantation with a history of multiple previous sternotomies.

ObjectivesThis study sought to characterize the echocardiographic findings of patients presenting with intravascular hemolysis (IVH) due to suspected continuous-flow left ventricular assist device (LVAD) pump thrombosis.BackgroundLVAD patients who develop pump thrombosis often present with IVH. Echocardiography may be able to detect device dysfunction in this setting.MethodsContinuous-flow LVAD patients presenting with IVH due to suspected pump thrombosis were identified. Patients underwent echocardiography with cannula Doppler flow velocity interrogation. Findings were compared with baseline and follow-up studies, and with 49 stable LVAD control patients.ResultsOf 145 patients, 14 (10%) had IVH due to suspected pump thrombosis. The mean age was 55 ± 15 years, 93% were men, and 50% received LVAD as destination therapy. Mean duration between implantation and IVH was 231 ± 218 days. Eleven (79%) patients presented with hemoglobinuria, 9 (64%) with jaundice, and 5 (36%) with acute heart failure. Reduced cannula diastolic flow velocity and increased systolic/diastolic (S/D) flow velocity ratio were the only echocardiographic parameters significantly different from controls (outflow cannula 0.3 ± 0.2 m/s vs. 0.8 ± 0.3 m/s, p = 0.03, and 5.9 ± 2.8 vs. 1.7 ± 0.7, p < 0.01, respectively), and were worse for IVH patients with acute heart failure compared with those without (outflow cannula 0.2 ± 0.1 m/s vs. 0.5 ± 0.2 m/s, p = 0.04, and 7.2 ± 3.3 vs. 5.3 ± 2.0, p = 0.02, respectively). Outflow cannula diastolic flow velocity and S/D flow velocity ratio changed significantly from baseline (p = 0.01 and p < 0.01, respectively) in IVH patients, whereas systolic flow velocity did not change (p = 0.59). Odds ratios for outflow cannula diastolic flow velocity and S/D flow velocity ratio for predicting IVH were 0.60 (95% confidence interval [CI]: 0.51 to 0.73), p = 0.02, and 2.45 (95% CI: 2.37 to 2.52) p < 0.01, respectively. Corresponding inflow cannula values were similarly significant. Pump thrombosis was confirmed in 7 (50%) patients after LVAD retrieval.ConclusionsReduced cannula diastolic flow velocity and increased S/D flow velocity ratio identified continuous-flow LVAD dysfunction in patients with IVH due to suspected pump thrombosis better than other echocardiographic parameters.

Background Coronary artery bypass graft surgery is superior to percutaneous intervention in diabetic patients with multivessel disease. The use of bilateral internal thoracic arteries (BITA) may provide better long-term graft patency, but the risk of postoperative deep sternal wound infection has limited its use in diabetic patients. However, studies have reported conflicting results, and require systematic evaluation. Methods MEDLINE, EMBASE, World of Science, and the Cochrane library were searched for randomized controlled trials and observational studies comparing the incidence of deep sternal wound infection in diabetic patients undergoing either left internal thoracic artery (LITA) or BITA harvest. We used random effect models to compare risk ratios within groups. Results One randomized controlled trial and 10 observational studies (126,235 diabetic patients: 122,465 LITA, 3,770 BITA) met inclusion criteria. Deep sternal wound infection occurred in 3.1% and 1.6% for the BITA and LITA cohorts, respectively. The risk ratio for deep sternal wound infection development was 1.71 (1.37 to 2.14) for BITA compared with LITA. Patients who underwent skeletonized BITA harvest had a similar risk of deep sternal wound infection compared with LITA (0.9 [0.42 to 2.09]), although pedicled harvest demonstrated increased risk (1.77 [1.4 to 2.23]). Early mortality was comparable in the LITA cohort (2.5%) and the BITA cohort (2.3%; p = 0.8). Conclusions The risk of deep sternal wound infection can be minimized in diabetic patients undergoing coronary artery bypass graft surgery by performing ITA harvested in a skeletonized manner with meticulous attention to preserving sternal blood flow. Pedicled harvest is to be discouraged when utilizing both ITA owing to a significant increase in the risk of postoperative deep sternal wound infection.

Background We developed and tested a clinical simulation program in the principles and conduct of postcardiotomy extracorporeal membrane oxygenation (ECMO) with the aim of improving confidence, proficiency, and crisis management. Methods Twenty-three thoracic surgery residents from unique residency programs participated in an ECMO course involving didactic lectures and hands-on simulation. A current postcardiotomy ECMO circuit was used in a simulation center to give residents training with basic operations and crisis management. Pretraining and posttraining assessments concerning confidence and knowledge were administered. Before and after the training, residents were asked to identify components of the ECMO circuit and manage crisis scenarios, including venous line collapse, arterial hypertension, and arterial desaturation. Results In the hands-on portion, residents had difficulty identifying the gas source and flow rate, centrifugal pump head inlet, and oxygenator outflow line. Timely and accurate ECMO component identification improved significantly after training. The arterial desaturation crisis scenario gave the residents difficulty, with only 22% providing the appropriate treatment recommendations in a timely and accurate fashion. At the end of the simulation training, most residents were able to manage the crises correctly in a timely manner. Posttraining confidence-related scores increased significantly. Most of the residents strongly recommended the course to their peers and reported simulation-based training was helpful in their postcardiotomy ECMO education. Conclusions We developed a simulation-based postcardiotomy ECMO training program that resulted in improved ECMO confidence in thoracic surgery residents. Crisis management in a simulated environment enabled residents to acquire technical and behavioral skills that are important in managing critical ECMO-related problems.

A 65-year-old male with dyspnoea and oedema from severe tricuspid regurgitation was referred for tricuspid valve (TV) surgery. He had undergone placement of a dual-chamber implantable cardioverter defibrillator (ICD) 15 years prior for dilated cardiomyopathy that was upgraded to a biventricular system with placement of a new right ventricular lead 3 years ago. Intraoperative 2D …

The goal of this study was to describe the predictors and significance of poor exercise tolerance after left ventricular assist device (LVAD) implantation. Despite LVAD therapy, some patients continue to exhibit exercise intolerance. The predictors and outcomes of these patients are unknown. A retrospective review of 65 LVAD recipients who performed 6-minute walk tests was conducted. Patients walking300 m were considered to have poor exercise tolerance. Twenty patients exhibited poor exercise tolerance (221 ± 45 m), compared to 45 patients with better exercise tolerance (406 ± 76 m). Postoperatively, poor performers were not easily identified by functional symptoms alone, because 42% of these patients reported New York Heart Association functional class I or II symptoms. Preoperative New York Heart Association class, inotrope therapy, and intra-aortic balloon pump use were similar between the 2 groups. Multivariate analysis using all adequately powered (n50) univariate predictors identified diabetes mellitus (odds ratio 10.493, p = 0.003) and elevated 1-month right atrial pressure (odds ratio 2.985 for every 5 mm Hg, p = 0.003) as significant predictors of poor performance (300 m; area under the curve 0.85). The poorly performing group had increased mortality (p = 0.011), with 21% increased risk for overall mortality for every 10 m short of 300 m (fitted Cox model: hazard ratio 1.211, p = 0.0001). The distance walked in meters in a postoperative 6-minute walk test was the strongest predictor of late post-LVAD mortality (p = 0.0002). In conclusion, despite similar severity of heart failure preoperatively, some LVAD recipients may have persistent exercise intolerance postoperatively as assessed by the 6-minute walk test that is independently associated with subsequent reduced survival.

ObjectivesThe aim of this study was to determine renal outcomes after left ventricular assist device (LVAD) implantation.BackgroundRenal dysfunction before LVAD placement is frequent, and it is unclear whether it is due to primary renal disease or to poor perfusion.MethodsA retrospective single-center analysis was conducted in 83 consecutive patients implanted with HeartMate II continuous-flow LVADs (Thoratec Corp., Pleasanton, California). Calculated glomerular filtration rate (GFR) was assessed on admission and 1, 3, and 6 months after implantation. To define predictors for improvement in GFR, clinical variables were examined in patients with decreased renal function (GFR 60 ml/min/1.73 m2. Univariate pre-operative predictors for improvement in renal function at 1 month included younger age (p = 0.049), GFR improvement with optimal medical therapy (p < 0.001), intra-aortic balloon pump use (p = 0.004), kidney length above 10 cm (p = 0.023), no treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (p = 0.029), higher bilirubin (p = 0.002), higher Lietz-Miller score (p = 0.019), and atrial fibrillation (p = 0.007). Multivariate analysis indicated pre-operative improved GFR (slope = 0.5 U per unit improved; 95% confidence interval: 0.2 to 0.8; p = 0.003), atrial fibrillation (slope = 27; 95% confidence interval: 8 to 46; p = 0.006), and intra-aortic balloon pump use (slope = 14; 95% confidence interval: 2 to 26; p = 0.02) as independent predictors.ConclusionsIn most patients with end-stage heart failure considered for LVAD implantation, renal dysfunction is reversible and likely related to poor renal perfusion.

Objectives Although primary transcatheter valve interventions have demonstrated acceptable early- and intermediate-term outcomes, data are lacking to guide patient selection for transcatheter valve-in-valve therapy. Furthermore, very few surgical benchmarks have been established for repeat conventional biological valve replacement to refine momentum for broad application of transcatheter intervention for a degenerated bioprosthesis. Methods From January 1993 to July 2014, 694 patients underwent repeat biological valve replacement at our clinic. Median age at repeat operation was 71 years (range, 26-95 years) and there were 437 men (63%). Hypertension was present in 453 patients (65%), diabetes in 128 patients (18%), prior myocardial infarction in 85 patients (12%), and prior stroke in 81 patients (12%). Prior coronary bypass grafting was performed in 212 patients (31%). Median left ventricular ejection fraction was 41% (range, 20-61) and New York Heart Association functional class III or IV was present in 529 patients (76%). Results Biological valve re-replacement included most commonly aortic valve in 464 patients (67%) and mitral valve in 170 (24%). Concomitant coronary bypass grafting was performed in 134 patients (19%). Mortality at 30 days occurred in 56 patients (8%). Multivariable analysis with backward stepwise regression identified New York Heart Association functional class (per 1 increment) (hazard ratio, 2.1; 95% confidence interval, 1.06-4.3; P = .03) and prior coronary bypass grafting (hazard ratio, 3.5; 95% confidence interval, 1.2-10.9; P = .03) as independent predictors of early death. Patients with the combination of prior coronary bypass grafting and New York Heart Association functional class III or IV accounted for 26 out of 56 early deaths (46%) and in the absence of this combination, early death in the cohort was 30 out of 694 (4%). Follow-up was available in 602 out of 638 early survivors (94%) for a median of 45 months (range, 1 month-23.4 years). Survival at 5 and 10 years was 63% and 34%, respectively. For patients who died during follow-up, 2-dimensional scatter plots demonstrate durable length of postoperative survival (median, 5.5 years; maximum, 22 years). Conclusions In a large population of patients undergoing repeat biological valve replacement, prior coronary bypass grafting and advanced New York Heart Association functional class were associated with increased 30-day mortality, with the remaining population having a low 30-day mortality of 4%. This study could serve as a surgical benchmark to guide patient selection for transcatheter valve-in-valve technology rather than employing a broader application of these techniques to those who may otherwise have low early risk of mortality and durable long-term survival after conventional valve surgery.