Saran, Nishant

We sought to characterize the long-term patency of various graft types in patients undergoing coronary artery bypass grafting. A comprehensive literature search identified 139 studies including 56,827 patients who underwent isolated coronary artery bypass grafting surgery. The mean patient age was 62 years (95% confidence interval: 60–63), and 80% (95% confidence interval: 79–82) were male. Patency outcomes were analyzed for each graft type, and parametric extrapolation was performed based on mean patency and mean follow-up time per conduit. The left internal mammary artery (LIMA) demonstrated the highest mean patency at 96% with a mean follow-up of 3.2 years, followed by the right internal mammary artery (RIMA) at 94% (2.8 years), gastroepiploic artery (GEA) at 93% (1.7 years), and radial artery (RA) at 89% (3.7 years). The saphenous vein graft had the lowest mean patency at 82% with a mean follow-up of 3.5 years. Extrapolated 20-year patency rates were 77% for LIMA, 64% for RIMA, 54% for RA, 42% for GEA, and 33% for saphenous vein graft. Arterial grafts demonstrated superior long-term patency compared to vein grafts. LIMA remains the primary conduit of choice, while RIMA, followed by RA and GEA, may be appropriate secondary arterial conduits depending on patient-specific factors. Vein grafts had the poorest long-term patency.

Abstract OBJECTIVES The purpose of this study was to assess the safety and efficacy of direct cannulation of the ascending aorta in comparison with cannulating peripheral arteries. METHODS We retrospectively analysed type A dissection patients [n = 107; median (interquartile range [IQR]) age, 64 [53–73] years] from January 2008 to March 2018. The cohort was divided into 2 groups: direct ascending aorta cannulation (group A, n = 47; median [IQR] age, 69 [54–74] years; 34% female) and non-aortic cannulation (group B, n = 60; median [IQR] age, 62 [52–72] years; 20% female). Postoperative outcomes and long-term survival were compared. RESULTS Baseline characteristics were not significantly different between the 2 groups, except for higher creatinine in group B (median 0.9 vs 1.1, P = 0.028) and higher prevalence of dyslipidaemia in group A (58.7% vs 38.3%, P = 0.037). Overall early mortality was 12.1% (n = 13); 12.8% (n = 6) in group A and 11.7% (n = 7) in group B (P = 0.863). The incidence of stroke was 10.6% (n = 5) in group A and 6.7% (n = 4) in group B (P = 0.463). After adjusting for CPB and circulatory arrest times, there was no group difference in the length of ICU (P = 0.257) or hospital stay (P = 0.118), all-cause reoperation (P = 0.709), peak postoperative creatinine (P = 0.426) and lactate values (n = 60; P = 0.862). Overall survival at 1, 3 and 5 years was 84%, 78% and 73%, respectively, with no difference between the 2 groups after adjustment (P = 0.629). CONCLUSIONS Direct cannulation of the ascending aorta is a safe cannulation strategy for type A dissection repair, offering the opportunity for rapid arterial cannulation and antegrade perfusion.

Type A aortic dissection most often requires emergent surgery to prevent malperfusion, stroke, and/or rupture of aorta. The conduct of the surgery is mostly targeted at restoring true lumen flow. In this regard, institution of cardiopulmonary bypass and circulation management is key to allow adequate systemic flow, perfusion of brain and visceral organs and comprehensive systemic cooling to achieve circulatory arrest when needed. Different strategies have been used with varying success rates, with the most common being femoral cannulation. More recently axillary and central cannulation strategies have shown satisfactory results with the promise of antegrade flow. Cannulation approach should, therefore, depend on individual patient characteristics, presentation and true lumen anatomy.

AbstractOBJECTIVESFunctional tricuspid regurgitation (fTR) has been amenable to tricuspid valve repair (TVr), with fewer patients needing tricuspid valve replacement (TVR). We sought to review our experience of tricuspid valve surgery for fTR.METHODSA retrospective analysis of adult patients (≥18 years) who underwent primary tricuspid valve surgery for fTR (n = 926; mean age 68.6 ± 12.5 years; 67% females) from January 1993 through June 2018 was conducted. There were 767 (83%) patients who underwent TVr (ring annuloplasty, 67%; purse-string annuloplasty, 33%) and 159 (17%) underwent TVR (bioprosthetic valves, 87%; mechanical valves, 13%). The median follow-up was 8.2 years [95% confidence interval (CI) 7.2–8.9 years].RESULTSA greater proportion of patients who underwent TVR had severe right ventricular dysfunction (P < 0.001), severe tricuspid regurgitation (P < 0.001) and congestive heart failure (P = 0.001) while the TVr cohort had a greater proportion with severe mitral valve (MV) regurgitation (P < 0.001) and concomitant cardiac procedures. Early mortality (TVR, 9% vs TVr, 3%; P = 0.004), renal failure (TVR, 10% vs TVr, 5%; P = 0.014) and hospital stay (TVR, 15 ± 15 days vs TVr, 12 ± 11 days; P < 0.001) were greater in TVR patients. The TVR cohort had worse survival [hazard ratio (HR) 1.57; 95% CI 1.23–1.99]. Multivariable analysis identified congestive heart failure (HR 1.37; 95% CI 1.10–1.72), renal failure (HR 1.79; 95% CI 1.14–2.82), previous MV surgery (HR 1.35; 95% CI 1.05–1.72) and TVR (HR 1.36; 95% CI 1.03–1.79) as independent risk factors for late mortality.CONCLUSIONSTricuspid repair for fTR appears to have better early and late outcomes. Since previous MV surgery and TVR are identified as independent risk factors for late mortality, concomitant TVr at the time of index MV surgery may be considered. Early referral before the onset of advanced heart failure may improve outcomes.

Abstract OBJECTIVES Limited literature is available on the best management strategy for tricuspid valve (TV) disease in adults. We sought to review our long-term outcomes of TV surgery with regard to survival and reoperation. METHODS A retrospective analysis of all patients ≥18 years of age [n = 2541, aged 67 ± 13years, 1433 (56%) females] who underwent first-time TV surgery between January 1993 and December 2013 was done. There were 1735 patients who received TV repair and 806 patients underwent replacement. A gradient boosting machine model was used to derive a propensity score for predicting replacement using 27 preoperative characteristics. Four hundred and eighteen propensity-matched pairs of TV repair and replacement were identified. Cox proportional hazard regression was used on the matched subset to determine the effect of replacement. RESULTS Functional TV regurgitation was present in 54% (n = 1369). A bioprosthesis was used in 84% (n = 680) of replacements, while 54% (n = 934) of TV repairs were ring annuloplasties. Operative mortality was 8% (n = 212). Overall survival was 54%, 29% and 13% at 5, 10 and 15 years, respectively. After propensity score matching, replacement was significantly associated with increased mortality [hazard ratio (HR) 1.54, 95% confidence interval (CI) 1.18–2.00; P = 0.001]. The cumulative incidence of TV reoperation was similar between the 2 groups when accounting for the competing risk of death [Fine–Gray HR 1.56, 95% CI 0.9–2.8; P = 0.144]. CONCLUSIONS TV surgery is associated with poor outcomes due to multiple patient comorbidities. TV repair results in better survival compared to replacement in patients with similar comorbidities with no increased risk of getting a reoperation.

Isolated aortic mural thrombus (AMT) is an infrequent occurrence in the setting of an otherwise normal aorta and is a similarly rare occurrence in Takayasu arteritis (TAK). As such, consensus on optimal treatment strategy does not exist, however, invariably necessitates anticoagulation. We report a case of a 21-year-old female who presented with acute chest pain with an isolated descending thoracic AMT on imaging. Diagnosis was elusive after an exhaustive, multidisciplinary evaluation including structural, hypercoagulable, and rheumatologic etiologies. After hypertension control and anticoagulation, she was asymptomatic without embolic sequelae. We proceeded with thoracic aortic resection with interposition reconstruction for the dual function of treatment and definitive diagnosis revealing TAK. This demonstrates a curious presentation of TAK with an equally atypical complication managed with surgery.