Dearani, Joseph A.

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.

Transaortic extended septal myectomy is the most reliable method for septal reduction for symptomatic patients with obstructive hypertrophic cardiomyopathy. In addition, surgical management of nonobstructive hypertrophic cardiomyopathy is possible for selected patients with diastolic heart failure and small left ventricular end-diastolic cavity dimensions. These procedures, however, are performed infrequently in many centers, and trainees may not be exposed to the preoperative evaluation and intraoperative management of patients with hypertrophic cardiomyopathy. In this paper, we review what we believe are the central features for creating a successful program for septal myectomy and detail our strategies to optimize instruction in these techniques for residents and fellows.

Background: Isolated anterior mitral valve clefts (MVC) are rare congenital heart defects, and data are limited regarding the natural history and surgical outcomes for such isolated MVCs. Methods: We conducted a retrospective review of patients with congenital MVC who were evaluated at Mayo Clinic in Rochester, Minnesota between 1993 and 2020. Patients were separated into two cohorts: those who underwent surgical repair of the MVC and those who had not yet undergone repair. Baseline and postoperative clinical and echocardiographic data were analyzed. Results: Fourteen patients were included in the nonsurgical cohort and eight patients in the surgical cohort. Surgical repair was via primary median sternotomy (n = 6) or robot-assisted, minimally invasive (n = 2). All cleft repairs were performed by simple suture closure. Intraoperative evaluation of the clefts did not reveal additional structural factors that could account for the mitral regurgitation (MR). At latest follow-up of the surgical cohort, the median grade of MR was 1 (range 0-1), and median left ventricular ejection fraction was 65% (IQR 59%-67%), both similar to the immediate postoperative result. At latest follow-up, all patients in the nonsurgical cohort were NYHA Class 1, and median MR grade was 1. All patients were asymptomatic (NYHA Class 1). Conclusions: Our findings corroborate prior reports that MVC repair is safe and successful and is followed by a low rate of recurrent mitral valve dysfunction. Durable surgical repair of isolated, congenital MVC can be performed safely in select patients. The decision to intervene should be based on the severity of mitral regurgitation and patient symptoms rather than the presence of the MVC alone.

Background Cardiovascular surgical outcomes reports are few for vascular type IV of Ehlers- Danlos Syndrome (vEDS) compared to non-vascular types I-III (nEDS). Methods To define cardiovascular surgical outcomes among adult patients (≥18 years) with EDS types, a review of our institution's in-house STS Adult Cardiac Surgery Database-compliant software and electronic medical records from Mayo Clinic (1993–2019) was performed. Outcomes were compared for vEDS patients and nEDS patients. Demographics, baseline characteristics, operative, in-hospital complications and follow-up vital status were analyzed. Results Over the study time frame, 48 EDS patients underwent surgery (mean age 52.6 ± 14.6 years; 48% females). Of these, 17 patients had vEDS and 31 patients had nEDS. Six patients (12.5%) underwent prior sternotomy. Urgent or emergent surgery was performed in 10 patients (20.8%). Aortic (vEDS 76.5% vs. nEDS 16.1%) and mitral procedures (vEDS 11.8% vs. nEDS 48.4%) were the two most common cardiovascular surgeries performed (p < .01 and p = .007, respectively). Cardiopulmonary bypass time (CPB) (165 ± 18 vs. 90 ± 13 min; p = .015) and aortic cross clamp times (140 ± 14 vs. 62 ± 10 min; p < .001) were longer for vEDS patients. There was 1 (2.1%) early and 7 (14.6%) late deaths; 6 among vEDS and 2 among nEDS patients. Survival at 5 (80% vs. 93%), 10 (45% vs. 84%) and 15 years (45% vs. 84%) was lower in patients with vEDS (p = .015 for each comparison). Conclusion Cardiovascular surgeries are significantly more complex with longer bypass and cross clamp times for type IV vEDS compared to nEDS patients. Reduced overall survival underscores the complexity and fragility of vEDS patients.

Background: There is a paucity of literature regarding systemic semilunar valve (SSLV) dysfunction in patients with Fontan circulation. We sought to describe our center's 47-year experience with systemic semilunar valve replacement or repair (SSLVR) in patients with Fontan circulation. Methods: The Mayo Clinic Fontan Database is a comprehensive institutional database that stores clinical information of 1176 patients from 1973 to 2021. It was reviewed to identify patients who had a SSLV intervention at the time of or after Fontan. A cohort of 15 patients was identified and a retrospective review of their records was performed. Results: Fourteen patients had SSLV replacement (all mechanical) and one had a repair. SSLVR occurred up to 29 years following the Fontan (mean 11.3 ± 9 years, median 14 years). Thirteen of 14 with SSLVR were performed after Fontan and one was done at the time of initial Fontan. This was an older cohort and mean age at the time of Fontan was 8.7 ± 9.4 years (median 4 years). Indication for the operation was > moderate SSLV regurgitation in all patients. Six patients had decreased ventricular function (EF < 50%) prior to SSLVR and 8 had reduced function after SSLVR. Conclusion: Fortunately, the need for SSLV intervention after Fontan was rare, as evidenced by our small cohort extracted from a large single-institution database spanning a 47-year time period. Reduced preoperative and postoperative ejection fraction was common but did not seem to impact the outcome. Optimal timing for SSLV intervention after Fontan remains unclear.

Background This study evaluated the role of supplementing Society of Thoracic Surgeons (STS) risk models for surgical aortic valve replacement with machine learning (ML). Methods and Results Adults undergoing isolated surgical aortic valve replacement in the STS National Database between 2007 and 2017 were included. ML models for operative mortality and major morbidity were previously developed using extreme gradient boosting. Concordance and discordance in predicted risk between ML and STS models were defined using equal‐size tertile‐based thresholds of risk. Calibration metrics and discriminatory capability were compared between concordant and discordant patients. A total of 243 142 patients were included. Nearly all calibration metrics were improved in cases of concordance. Similarly, concordance indices improved substantially in cases of concordance for all models with the exception of deep sternal wound infection. The greatest improvements in concordant versus discordant cases were in renal failure: ML model (concordance index, 0.660 [95% CI, 0.632–0.687] discordant versus 0.808 [95% CI, 0.794–0.822] concordant) and STS model (concordance index, 0.573 [95% CI, 0.549–0.576] discordant versus 0.797 [95% CI, 0.782–0.811] concordant) (each P <0.001). Excluding deep sternal wound infection, the concordance indices ranged from 0.549 to 0.660 for discordant cases and 0.674 to 0.808 for concordant cases. Conclusions Supplementing ML models with existing STS models for surgical aortic valve replacement may have an important role in risk prediction and should be explored further. In particular, for the roughly 25% to 50% of patients demonstrating discordance in estimated risk between ML and STS, there appears to be a substantial decline in predictive performance suggesting vulnerability of the existing models in these patient subsets.

In adult congenital heart disease, there are situations that require both the aortic and pulmonary roots to be replaced at the time of a reoperation. This commonly involves the replacement of a previously implanted right ventricle-pulmonary artery conduit in a patient with late aortic root dilation and/or neo-aortic valve dysfunction following the Ross procedure. Similar scenarios are encountered in patients having undergone previous repair of conotruncal anomalies such as truncus arteriosus and tetralogy of Fallot with pulmonary atresia. We describe our standardized technique for twin root replacement.

Three-dimensional (3D) modeling has become an invaluable tool for operative planning in the continually evolving complex field of adult congenital heart surgery. We present a case of an intra-atrial conduit leak after multiple repairs of common atrium and criss-cross morphology. 3D modeling was critical in preoperative evaluation and operative planning for complicated intracardiac anatomy after an uncommon initial approach to preserve a biventricular circulation. In the setting of complex or rare congenital cardiac anomalies, advanced imaging and 3D modeling are helpful with preoperative planning.