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BACKGROUND AND AIM To compare outcomes of patients treated with inhaled epoprostenol and low tidal volume ventilation during cardiopulmonary bypass with those who did not receive this medication in the operating room at all, and those who received it as a rescue therapy at the end of the case. METHODS Retrospective chart review between 2014 and 2017, follow-up included the entire hospital stay. RESULTS Seventy-one patients were included, and mean age was 54 years. 78.9% of the patients were male. Procedures included 96% (n = 68) aortic valve replacement, 28% (n = 20) reconstruction of the intravalvular fibrosa, and 13% (n = 9) repair of an endocarditis-related intracardiac fistula. Patients who received epoprostenol (iEpo) (treatment and rescue groups), when compared with the control group had more intra-aortic balloon pump placement (23% vs 2.5%, P = .018), open chest after surgery (32% vs 7.5%, P = .012), and duration of mechanical ventilation (8.3 ± 2.7 vs. 2.4 ± 0.4 days, P = 0.01). There was no significant difference between the two groups in terms of extracorporeal circulatory support (6.5% vs 2.5%, P = .577) and hospital death (13% vs 10%, P = .72). In a subanalysis, hospital death and duration of mechanical ventilation were higher in the recue group when compared with the treatment group (P = .004 and .056, respectively). CONCLUSIONS Prophylactic application of iEpo with low tidal volume ventilation for an anticipated complex endocarditis operation may contribute to favorable outcome when compared with postoperative epoprostenol rescue.

Background Recurrence and overall survival for incidental lung cancer in explanted lungs vary between different series. Recurrence patterns are also not well described. The primary objective of this study is to study the recurrence patterns and time to recurrence for various stages of lung cancer in lung transplant recipients. Methods A retrospective review of our institutional database was performed to identify patients who had incidental lung cancer found in transplant pneumonectomy specimens from 1990 to 2017. Demographic, radiographic, and perioperative clinical variables were collected. Time to recurrence, overall survival, and recurrence patterns were recorded. Freedom from recurrence and overall survival were estimated by using Kaplan-Meier analysis. Results Thirty-one patients had unexpected malignancy and 29 patients (1.6%) had primary lung carcinoma in the explanted lung. Indication for transplantation was chronic obstructive pulmonary disease in 15 patients (48%) and interstitial lung disease for 16 patients (52%). Preoperative imaging showed indeterminate nodules in 10 patients (32%). Pathologic review showed stage I disease in 15 patients (54%), stage II disease in 10 patients (35%), and stage III disease in 2 patients (7%). Recurrence was noted in 8 patients (28%). Most patients had nodal disease (25%) or systemic recurrence (75%). All recurrences occurred within 2 years of the transplantation. For patients with stage I and II disease, freedom from recurrence at 1, 3, and 5 years was 91%, 55%, and 55%, respectively. Overall survival at 1, 3, and 5 years was 78%, 18%, and 14%, respectively. Conclusions Most recurrences occur within 2 years after transplantation and are the cause of death in these patients. Patients with nodal disease tend to have higher recurrence rates. Multidisciplinary review of abnormal radiographic findings before transplantation and close follow-up may allow for detection of undiagnosed cancers.

Background Reconstruction of the intervalvular fibrosa (IVF) for invasive double-valve infective endocarditis (IE) is a technically challenging operation. This study presents the long-term outcomes of two surgical techniques for IVF reconstruction. Methods From 1988 to 2017, 138 patients with invasive double-valve IE underwent surgical reconstruction of the IVF, along with double-valve replacement (Commando procedure, n = 86) or aortic valve replacement with mitral valve repair (hemi-Commando procedure, n = 52). Mean follow-up was 41 ± 5.9 months. Results Reoperation was required in 82% of patients, and 34% underwent emergency surgery. Pathologic features included positive blood cultures (90%), prosthetic valve IE (75%), aortic root abscess (78%), mitral annular abscess (24%), and intracardiac fistula (12%). There were 28 hospital deaths: 21 (24%) in the Commando group and 7 (14%) in the hemi-Commando group (P = .12). Overall survival at 1, 5, and 10 years was 67%, 48%, and 37%, respectively. Coronary artery disease, native valve IE, and causative organism (Staphylococcus aureus, coagulase-negative Staphylococcus, and viridans streptococci) were risk factors for late mortality. Freedom from reoperation at 1, 5, and 8 years was 87%, 74%, and 55%, respectively. Freedom from recurrent IE at 1, 5, and 8 years was 90%, 78%, and 67%, respectively. Conclusions Although it is technically demanding, surgery for invasive IE involving IVF, which provides the only chance for cure, can be performed with reasonable clinical outcomes. In cases of IE invading the IVF and limited to the anterior mitral valve leaflet, a hemi-Commando procedure that includes mitral valve repair has improved early outcomes.

The aim of this study was to determine if transcutaneous CO(2) monitoring (TCO(2)) is feasible to avoid hypercapnia during complex catheter ablation. Cumulative analgesic and anxiolytic effects during complex catheter ablation can rarely provoke hypoventilation and respiratory complications. End tidal CO(2) monitors have limitations in non-ventilated patients, and frequent arterial blood gas sampling is impractical.Consecutive patients undergoing catheter ablation for atrial fibrillation (AF) or ventricular tachycardia (VT) received continuous TCO(2) monitoring. Procedural evaluation of TCO(2) was performed concomitantly with point-of-care arterial blood gas testing. Endpoints included PCO(2) protocol feasibility, TCO(2)/PCO(2) agreement, and avoidance of hypercapnia-related procedural complications.Fifty patients [AF n = 36 (72 %), VT n = 14 (28 %)] underwent catheter ablation (mean 221.7 ± 57.0 min duration, median 41.4 ± 21.1 min fluoroscopy) in which 6.0 ± 2.6 mg midazolam and 449 ± 225.5 mcg of fentanyl were administered. Monitoring protocol implementation was feasible in 50/50 (100 %) cases. Protocol-driven anesthesia consultation avoided an unplanned intubation in 1 case (2 %) and there was only 1 unplanned intubation (2 %) for oxygen desaturation due to heart failure without hypercapnia during a VT ablation (TCO(2)/PCO(2) agreement5 mmHg). There were no respiratory or pulseless electrical arrests (0 %) in the study. TCO(2) and PCO(2) correlated well (baseline: r = 0.75, p 0.001; 1 h:r= 0.72, p 0.001; 2 h: r = 0.55, p = 0.003; 3 h: r = 0.79, p = 0.02). However, desired agreement was lower than expected [baseline: 33/50 (66 %) 5 mmHg, 48/50 (96 %) 10 mmHg; 1 h: 29/45 (64 %) 5 mmHg, 39/45 (87 %) 10 mmHg; 2 h: 14/26 (54 %) 5 mmHg, 22/26 (85 %) 10 mmHg; 3 h: 7/11 (64 %) 5 mmHg, 10/11 (91 %) 10 mmHg;3 h: 1/3 (33 %) 5 mmHg, 2/3 (66 %) 10 mmHg].Transcutaneous CO2 monitoring is feasible during complex catheter ablation and correlates with invasively obtained data. However, further development is needed to achieve the desired level of agreement.

Background A novel technology incorporates electrodes into an iPhone case that records an electrocardiographic tracing. Objectives The objectives of this study were to examine the feasibility and efficacy of this technology to monitor patients after the atrial fibrillation (AF) ablation procedure and to assess patients' feedback on its ease of use. Methods Patients with AF undergoing ablation who had iPhones were screened for enrollment. They were provided with an AliveCor heart monitor (AHM) case and a traditional transtelephonic monitor (TTM). Patients were asked to record their rhythm using both monitors simultaneously whenever they had symptoms or at least once a week. AHM recordings were sent to a secure e-mail account, and TTM recordings were transmitted to our Holter laboratory using landlines. All AHM recordings were reviewed by 1 of 2 blinded electrophysiologists. TTM recordings were reviewed by the primary electrophysiologist. The κ coefficient was calculated to assess agreement between AHM and TTM recordings. Sensitivity and specificity for the detection of AF and atrial flutter with the AHM compared to the TTM were calculated. Results Sixty patients were enrolled (mean age 60 ± 12 years), and 55 completed the study. There were 389 simultaneous AHM and TTM recordings. The κ statistic was 0.82, indicating excellent agreement between AHM and TTM recordings. If we consider AF and atrial flutter as one diseased state, the AHM had 100% sensitivity and 97% specificity for the detection of AF and atrial flutter. Only 2% of patients found it difficult to use the AHM, and the large majority (92%) preferred to use the AHM to monitor their AF as opposed to the TTM. Conclusion The AHM is an alternative method for monitoring patients with AF after the ablation procedure. Most patients found it easy to use.

Objectives Surgical management of invasive double-valve infective endocarditis (IE) involving the intervalvular fibrosa (IVF) is a technical challenge that requires extensive debridement followed by complex reconstruction. In this study, we present the early and mid-term outcomes of the hemi-Commando procedure and aortic root replacement with reconstruction of IVF using an aortomitral allograft. Methods From 2010 to 2017, 37 patients with IE involving the IVF underwent the hemi-Commando procedure. Postoperative clinical data and echocardiograms were reviewed for the assessment of cardiac structural integrity and clinical outcomes. Results Twenty-nine (78%) cases were redo surgery and 15 (41%) were emergency surgery. Preoperatively, 70% (n = 26) of patients were admitted to the intensive care unit and 11% (n = 4) of patients were in septic shock. Ten (27%) patients had native aortic valve IE, while 27 (73%) patients had prosthetic valve IE. Hospital death occurred in 8% (n = 3) of patients due to multisystem organ failure. Postoperative echocardiogram showed no aortic regurgitation in 86% (n = 32) and mild regurgitation in 14% (n = 5) of patients, while mitral regurgitation prevalence was none/trivial in 62% (n = 23), mild in 32% (n = 12) and moderate in 5%. Intact IVF reconstruction was confirmed in all patients with no abnormal communication between the left heart chambers. One-year survival was 91%, while 3-year survival was 82%. Mid-term follow up revealed 1 death secondary to recurrent IE. Conclusions Compared to double-valve replacement with IVF reconstruction ('Commando operation'), the early and mid-term outcomes of the hemi-Commando procedure proved to be a feasible treatment option for IVF reconstruction, enabling preservation of the mitral valve and the subvalvular apparatus in high-risk patients with invasive double-valve IE.

Background Extracorporeal membrane oxygenation (ECMO), when used as bridge to lung transplantation, (BTT) identifies high-risk candidates. Recent advances in cannula design and patient selection fosters “awake ambulatory ECMO” as a viable option for critically ill candidates in an attempt to retard deconditioning while awaiting allografts. Methods From 2012 to 2015, 30 patients underwent ECMO as BTT. Candidacy for ECMO was determined before listing for transplant. A dual-lumen single cannula was used first in 13 of 30 patients (43%). Of the remaining 30 patients, 6 (20%) were supported with venoarterial ECMO and 11 (37%) with venovenous ECMO, with double-site cannulation in 11 (37%), and 6 of 11 converted to a dual-lumen single cannula. All ECMO patients were managed in a dedicated heart/lung failure intensive care unit, and early aggressive physical therapy, ambulation, and spontaneous breathing trials were emphasized. Results BTT was successful in 26 patients (87%). In the 19 patients with dual-lumen single cannula, 5 (26%) were successfully ambulated, and 6 (32%) achieved spontaneous ventilation. Median (25th, 75th percentile) lengths of stay in the intensive care unit and hospital were 33 days (20, 46 days) and 56 days (28, 78 days), respectively, and were 20 and 31 days, respectively, in patients successfully ambulated (intensive care unit: p = 0.5; hospital: p = 0.4). Among all patients who received a transplant, 30-day, 1-year, and 3-year survival were 92%, 85%, and 80%, respectively. Among patients undergoing primary transplants, 3-year survival was 91%. Conclusions ECMO as BTT has led to encouraging perioperative outcomes and early survival. Careful patient selection and early use of ECMO seems to allow for preservation of vitality while these critically ill candidates await donor organs, which may improve outcomes.

Background— Achieving long-term successful outcomes with ablation of persistent atrial fibrillation (AF) remains a clinical and procedural challenge. We aimed to assess 2 ablation strategies for persistent AF: pulmonary vein antral isolation (PVAI) in sinus rhythm after direct current cardioversion versus PVAI and ablation targeting complex-fractionated atrial electrograms while in AF. Methods and Results— Between June 2009 and July 2013, patients with continuous persistent AF for ≥3 months were prospectively randomized to either direct current cardioversion before PVAI and posterior wall/septum ablation while in sinus rhythm (group 1), versus same ablation in group 1 in addition to complex-fractionated atrial electrogram ablation while in AF (group 2). The procedural profiles and clinical outcomes of the 2 strategies were compared. Ninety patients were randomized to group 1 (n=46) or group 2 (n=44). There were no differences in baseline characteristics between groups. Over 365 days of follow-up after the index procedure, 16 patients (35%) in group 1 and 13 patients (30%) in group 2 remained arrhythmia-free off antiarrhythmic medications. Over long-term follow-up (median, 867 days), arrhythmia-free survival off antiarrhythmic medications was more likely in group 1 than in group 2 in Kaplan–Meier analysis (Log Rank P =0.04). Group 1 ablation was associated with significantly shorter procedural duration and fluoroscopy time (231±72 versus 273±76 min; P =0.008 and 54 [Q1–Q3: 46–67] versus 66 (Q1–Q3: 53–83] min; P =0.018, respectively). Conclusions— In patients with persistent AF, PVAI in sinus rhythm after direct current cardioversion is associated with higher success and shorter procedural and fluoroscopy times compared with PVAI in AF with additional complex-fractionated atrial electrogram ablation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT02429648.

Background— Various ablation strategies of persistent atrial fibrillation (PersAF) have had disappointing outcomes, despite concerted clinical and research efforts, which could reflect progressive atrial fibrillation–related atrial remodeling. Methods and Results— Two-year outcomes were assessed in 1241 consecutive patients undergoing first-time ablation of PersAF (2005–2012). The time intervals between the first diagnosis of PersAF and the ablation procedures were determined. Patients had echocardiograms and measures of B-type natriuretic peptide and C-reactive protein before the procedures. The median diagnosis-to-ablation time was 3 years (25th–75th percentiles 1–6.5). With longer diagnosis-to-ablation time (based on quartiles), there was a significant increase in recurrence rates in addition to an increase in B-type natriuretic peptide levels ( P =0.01), C-reactive protein levels ( P P =0.03). The arrhythmia recurrence rates over 2 years were 33.6%, 52.6%, 57.1%, and 54.6% in the first, second, third, and fourth quartiles, respectively ( P categorical P P categorical Conclusions— In patients with PersAF undergoing ablation, the time interval between the first diagnosis of PersAF and the catheter ablation procedure had a strong association with the ablation outcomes, such as shorter diagnosis-to-ablation times were associated with better outcomes and in direct association with markers of atrial remodeling.

Introduction: Persistent atrial fibrillation (PerAF) ablation has been associated with significant recurrence rates which could reflect progressive AF-related atrial remodeling. We hypothesized that the first-diagnosis to ablation time for PerAF is a major determinant of success rates and in direct association with pathways of atrial remodeling. Methods: Two-year outcomes were assessed in 1241 patients undergoing first time ablation of PerAF between January 2005 and December 2012 at our institution. The time intervals between the first diagnosis of PerF and the ablation procedures were determined. Patients had echocardiograms and measures of B-type natriuretic peptide (BNP) and C-reactive protein (CRP) before the ablation procedures. During ablations, patients with atrial scarring by voltage were identified. Results: The median time-to-ablation since the first PerAF diagnosis was 3 years (interquartile range 1-6.5). With longer diagnosis-to-ablation time (based on quartiles), there was a significant increase in BNP levels (p=0.01), CRP levels (p Conclusions: The success rates with PerAF ablation are highest with early intervention, that is ablation before the progression of atrial remodeling.