Daly, Richard C.

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.

Background – The impact of post-operative complications on long-term survival is not well characterized. We sought to study the prevalence of post-operative complications after cardiac surgery and their impact on long-term survival. Methods – Operative survivors (n=26,221) who underwent coronary artery bypass grafting (CABG) (n=13054, 49.8%), valve surgery (n=8667, 33.1%) or combined CABG and valve surgery (n=4500, 17.2%) from 1993 to 2019 were included in the study. Records were reviewed for post-operative complications and long-term survival. The associations between post-operative complications and survival were assessed using a Cox-proportional model. Results – Complications occurred in 17,463 (66.6%) of 26,221 operative survivors. A total of 17 post-operative complications were analyzed. Post-operative blood product use was the commonest (n=12397, 47.3%), followed by atrial fibrillation (n=8399, 32.0%), prolonged ventilation (n=2336, 8.9%), renal failure (n=870, 3.3%), re-operation for bleeding (n=859, 3.3%) and pacemaker/ICD insertion (n=795, 3.0%). Stroke (HR 1.55, 95%CI 1.36-1.77), renal failure (HR 1.45, 95% CI 1.33-1.58) anticoagulant-related events (HR 1.26, 95%CI 1.02-1.56) and pneumonia (HR 1.23, 95%CI 1.11-1.36) had the strongest impact on long-term survival. Long-term survival decreased as the number of post-operative complications increased. Conclusions – Post-operative complications after cardiac surgery significantly impact outcomes that extend beyond the post-operative period. The presence, number and type of post-operative complications adversely impact long-term survival. Stroke, renal failure, anticoagulant-related events and pneumonia are particularly associated with poor long-term survival.

Utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is expanding, but dual VA-ECMO circuits to treat cardiogenic shock with refractory hypoxemia is unreported. We describe the case of combined cardiogenic and distributive shock due to necrotizing pulmonary blastomycosis. After initial central VA-ECMO cannulation, acute respiratory distress syndrome (ARDS) with increasing shunt resulted in significant central hypoxemia due to progressive ventilation-perfusion mismatch. An additional circuit provided complete oxygenation of the high circulating volume. After 4 months on support, he underwent successful heart-lung-kidney transplantation. Dual ECMO circuits are technically feasible and may be advantageous in specific circumstances of high pulmonary shunting resulting in excessive hypoxemia unbalanced with appropriate oxygen delivery.

Background The presence of a durable left ventricular assist device ( LVAD ) is associated with increased risk of vasoplegia in the early postoperative period following heart transplantation ( HT ). However, preoperative predictors of vasoplegia and its impact on survival after HT are unknown. We sought to examine predictors and outcomes of patients who develop vasoplegia after HT following bridging therapy with an LVAD . Methods and Results We identified 94 patients who underwent HT after bridging with continuous‐flow LVAD from 2008 to 2018 at a single institution. Vasoplegia was defined as persistent low vascular resistance requiring ≥2 intravenous vasopressors within 48 hours after HT for >24 hours to maintain mean arterial pressure >70 mm Hg. Overall, 44 patients (46.8%) developed vasoplegia after HT . Patients with and without vasoplegia had similar preoperative LVAD , echocardiographic, and hemodynamic parameters. Patients with vasoplegia were significantly older; had longer LVAD support, higher preoperative creatinine, longer cardiopulmonary bypass time, and higher Charlson comorbidity index; and more often underwent combined organ transplantation. In a multivariate logistic regression model, older age (odds ratio: 1.08 per year; P =0.010), longer LVAD support (odds ratio: 1.06 per month; P =0.007), higher creatinine (odds ratio: 3.9 per 1 mg/dL; P =0.039), and longer cardiopulmonary bypass time (odds ratio: 1.83 per hour; P =0.044) were independent predictors of vasoplegia. After mean follow‐up of 4.0 years after HT , vasoplegia was associated with increased risk of all‐cause mortality (hazard ratio: 5.20; 95% CI, 1.71–19.28; P =0.003). Conclusions Older age, longer LVAD support, impaired renal function, and prolonged intraoperative CPB time are independent predictors of vasoplegia in patients undergoing HT after LVAD bridging. Vasoplegia is associated with worse prognosis; therefore, detailed assessment of these predictors can be clinically important.

Abstract Background: Patients with AL and congestive heart failure have a median survival of less than one year. Methods: Between 1994 and 2005, 11 patients underwent sequential heart transplant followed by autologous peripheral blood stem cell transplant (SCT) for treatment of AL. Patients had heart dominant AL with minimal/no other organ impairment and no evidence of multiple myeloma. Results: Patients ranged in age from 35 to 63 years (median 54). All had biopsy proven amyloidosis and monoclonal protein detectable in serum (73%) or urine (100%). Free light chain assay was available prior to SCT in 6 and was abnormal in all. All patients presented with NYHA Class III or IV heart failure. All but two patients had no other organ involved at the time of heart transplant. One patient had his heart transplant at another facility and had renal involvement at the time of heart transplant. One patient had peripheral nerve involvement documented prior to heart transplant. Five patients had progression of amyloid to involve other organs by the time of SCT. These included: renal (6), peripheral nerve (2), macroglossia (3), gastrointestinal (2). The median time from diagnosis to heart transplant was 3 months (range 1 to 5). The median time from heart transplant to SCT was 8 months, (range 3 to 24). Conditioning chemotherapy consisted of melphalan 200 mg /m2 (6 patients) or melphalan 140 mg/m2 (5 patients). Two patients died of complications before day +100, (TRM of 18%). Hematologic remissions were seen in 8 and organ responses in 3. Five were unable to be evaluated for organ response due to the heart transplant. Three died from progressive amyloidosis at 66, 56.7, and 55 months following SCT. The median survival is 56.7 months from SCT. Six are alive with a median follow-up of 24 months, range 9 to 90 months. Among the 6 surviving patients, one patient relapsed and one patient has failed to improve, but 4 patients are in continued remission. One patient developed secondary myelodysplastic syndrome. Conclusions: Heart transplant followed by SCT is feasible and offers durable remissions for carefully selected patients with cardiac AL. Figure Figure

Background Diastolic pulmonary gradient ( DPG ) was proposed as a better marker of pulmonary vascular remodeling compared with pulmonary vascular resistance ( PVR ) and transpulmonary gradient ( TPG ). The prognostic significance of DPG in patients requiring a left ventricular assist device ( LVAD ) remains unclear. We sought to investigate whether pre‐ LVAD DPG is a predictor of survival or right ventricular ( RV ) failure post‐ LVAD . Methods and Results We retrospectively reviewed 268 patients who underwent right heart catheterization before LVAD implantation from 2007 to 2017 and had pulmonary hypertension because of left heart disease. Patients were dichotomized using DPG ≥7 mm Hg, PVR ≥3 mm Hg, or TPG ≥12 mm Hg. The associations between these parameters and all‐cause mortality or RV failure post LVAD were assessed with Cox proportional hazards regression and Kaplan–Meier analyses. After a mean follow‐up time of 35 months, elevated DPG was associated with increased risk of RV failure (hazard ratio [ HR ]: 3.30; P =0.004, for DPG ≥7 versus DPG <7), whereas elevated PVR ( HR 1.85, P =0.13 for PVR ≥3 versus PVR <3) or TPG ( HR 1.47, P =0.35, for TPG ≥12 versus TPG <12) were not associated with the development of RV failure. Elevated DPG was not associated with mortality risk ( HR 1.16, P =0.54, for DPG ≥7 versus DPG <7), whereas elevated PVR , but not TPG , was associated with higher mortality risk ( HR 1.55; P =0.026, for PVR ≥3 versus PVR <3). Conclusions Among patients with pulmonary hypertension because of left heart disease requiring LVAD support, elevated DPG was associated with RV failure but not survival, while elevated PVR predicted mortality post LVAD implantation.

AbstractBackgroundLung transplant recipients are prone to invasive fungal infections prompting many transplant centers to use prolonged triazole antifungal prophylaxis. From a practical standpoint, it is unclear if lung transplant recipients are able to continue prolonged or lifelong prophylaxis without premature discontinuation from side effects, drug interactions, development of fungal disease, or medication cost. We examined the number of patients that are able to reach a prophylactic endpoint and understand the reasons for early termination.MethodsWe conducted a retrospective chart review of all lung and heart‐lung transplant patients at Mayo Clinic Rochester from May 1, 2002 to December 31, 2017. Type, duration, and reason for discontinuation of triazole prophylaxis were examined.ResultsDuring the study period, 193 patients underwent lung or heart‐lung transplantation. Itraconazole, voriconazole, and posaconazole were given to 180, 73, and 60 post‐transplant patients, respectively. Providers switched itraconazole to another prophylactic antifungal medication for reasons other than prophylactic completion in 61.8% (126 out of 204) of exposure episodes; this was similar with voriconazole (68.8%, 53 out of 77, P = 0.41). Posaconazole was actively discontinued significantly less often (18.3%, 11 out of 60, P < 0.05). The most common reasons for discontinuing itraconazole were malabsorption (15.5% of exposure episodes) and concern for breakthrough fungal infection (10.2%). In comparison, the most common reason for voriconazole discontinuation was side effect or intolerance (54.5% of VR exposure episodes vs 9.8% of IT exposure episodes, P < 0.05).ConclusionsItraconazole and posaconazole appeared to have fewer side effects prompting discontinuation than voriconazole, but itraconazole was discontinued more often because of malabsorption and clinical suspicion of fungal infections.

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.