Minimally Invasive Mitral Valve Surgery III: Training and Robotic-Assisted Approaches.

Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program

Minimally Invasive Mitral Valve Surgery I: Patient Selection, Evaluation, and Planning.

Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection

Minimally Invasive Mitral Valve Surgery II: Surgical Technique and Postoperative Management.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery

Comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in a real-world Surgical Treatment for Ischemic Heart Failure trial population.

OBJECTIVE: There are no prospective randomized trial data to guide decisions on optimal revascularization strategies for patients with multivessel coronary artery disease and reduced ejection fraction. In this analysis, we describe the comparative effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in this patient population. METHODS: A multicenter, retrospective analysis of all CABG (n = 18,292) and PCIs (n = 55,438) performed from 2004 to 2014 among 7 medical centers reporting to the Northern New England Cardiovascular Disease Study Group. After applying inclusion and exclusion criteria from the Surgical Treatment for Ischemic Heart Failure trial, there were 955 CABG and 718 PCI patients with an ejection fraction ≤ 35% and 2- or 3-vessel disease. Inverse probability weighting was used for risk adjustment. The primary end point was all-cause mortality. Secondary end points included rates of 30-day mortality, stroke, acute kidney injury, and incidence of repeat revascularization. RESULTS: The median duration of follow-up was 4.3 years (range, 1.59-6.71 years). CABG was associated with improved long-term survival compared with PCI after risk adjustment (hazard ratio, 0.59; 95% confidence interval, 0.50-0.71; P \u3c .01). Although CABG and PCI had similar 30-day mortality rates (P = .14), CABG was associated with a higher frequency of stroke (P \u3c .001) and acute kidney injury (P \u3c .001), whereas PCI was associated with a higher incidence of repeat revascularization (P \u3c .001). CONCLUSIONS: Among patients with reduced ejection fraction and multivessel disease, CABG was associated with improved long-term survival compared with PCI. CABG should be strongly considered in patients with ischemic cardiomyopathy and multivessel coronary disease

Tissue versus mechanical aortic valve replacement in younger patients: A multicenter analysis.

OBJECTIVE: The goal of this study was to examine the long-term survival of patients between the ages of 50 and 65 years who underwent tissue versus mechanical aortic valve replacement (AVR) in a multicenter cohort. METHODS: A multicenter, retrospective analysis of all AVR patients (n = 9388) from 1991 to 2015 among 7 medical centers reporting to a prospectively maintained clinical registry was conducted. Inclusion criteria were: patients aged 50 to 65 years who underwent isolated AVR. Baseline comorbidities were balanced using inverse probability weighting for a study cohort of 1449 AVRs: 840 tissue and 609 mechanical. The primary end point of the analysis was all-cause mortality. Secondary end points included in-hospital morbidity, 30-day mortality, length of stay, and risk of reoperation. RESULTS: During the study period, there was a significant shift from mechanical to tissue valves (P \u3c .001). There was no significant difference in major in-hospital morbidity, mortality, or length of hospitalization. Also, there was no significant difference in adjusted 15-year survival between mechanical versus tissue valves (hazard ratio, 0.87; 95% confidence interval [CI], 0.67-1.13; P = .29), although tissue valves were associated with a higher risk of reoperation with a cumulative incidence of 19.1% (95% CI, 14.4%-24.3%) versus 3.0% (95% CI, 1.7%-4.9%) for mechanical valves. The reoperative 30-day mortality rate was 2.4% (n = 2) for the series. CONCLUSIONS: Among patients 50 to 65 years old who underwent AVR, there was no difference in adjusted long-term survival according to prosthesis type, but tissue valves were associated with a higher risk of reoperation

Does Use of Bilateral Internal Mammary Artery Grafting Reduce Long-Term Risk of Repeat Coronary Revascularization? A Multicenter Analysis.

BACKGROUND: Although previous studies have demonstrated that patients receiving bilateral internal mammary artery (BIMA) conduits during coronary artery bypass grafting have better long-term survival than those receiving a single internal mammary artery (SIMA), data on risk of repeat revascularization are more limited. In this analysis, we compare the timing, frequency, and type of repeat coronary revascularization among patients receiving BIMA and SIMA. METHODS: We conducted a multicenter, retrospective analysis of 47 984 consecutive coronary artery bypass grafting surgeries performed from 1992 to 2014 among 7 medical centers reporting to a prospectively maintained clinical registry. Among the study population, 1482 coronary artery bypass grafting surgeries with BIMA were identified, and 1297 patients receiving BIMA were propensity-matched to 1297 patients receiving SIMA. The primary end point was freedom from repeat coronary revascularization. RESULTS: The median duration of follow-up was 13.2 (IQR, 7.4-17.7) years. Patients were well matched by age, body mass index, major comorbidities, and cardiac function. There was a higher freedom from repeat revascularization among patients receiving BIMA than among patients receiving SIMA (hazard ratio [HR], 0.78 [95% CI, 0.65-0.94]; CONCLUSIONS: BIMA grafting was associated with a reduced risk of repeat revascularization and an improvement in long-term survival and should be considered more frequently during coronary artery bypass grafting

Surgical Atrial Fibrillation Ablation Improves Long-Term Survival: A Multicenter Analysis.

BACKGROUND: The Society of Thoracic Surgeons guidelines recommend surgical ablation (SA) at the time of concomitant mitral operations, aortic valve replacement, coronary artery bypass grafting (CABG), and aortic valve replacement plus CABG for patients in atrial fibrillation (AF). The goal of this analysis was to assess the influence of SA on long-term survival. METHODS: A retrospective analysis of 20,407 consecutive CABG or valve procedures from 2008 to 2015 among seven centers reporting to a prospectively maintained clinical registry was conducted. Patients undergoing operation with documented preoperative AF were included (n = 2,740). Patients receiving SA were compared with patients receiving no SA. The primary end point was all-cause mortality. Secondary end points included in-hospital morbidity and mortality. RESULTS: The frequency of SA was 23.1% (n = 634), and an increase was seen in the rate of SA over the study period (p \u3c 0.001). Concomitant SA was performed in 16.2% of CABG, 30.6% of valve, and 24.3% of valve plus CABG procedures. A substantial improvement was found in unadjusted survival among patients undergoing SA (hazard ratio 0.54, 95% confidence interval: 0.42 to 0.70). Moreover, no differences were found in postoperative complications. SA did have longer bypass times (p \u3c 0.001) but a shorter overall length of stay (p \u3c 0.001). After risk adjustment, SA patients had an improved 5-year survival (hazard ratio 0.69, 95% confidence interval: 0.51 to 0.92), and the effect was observed across all operations. CONCLUSIONS: In a multicenter cohort of patients with AF, concomitant SA resulted in substantially improved long-term survival across patients who underwent CABG, valve, and valve plus CABG. These findings support current guidelines from The Society of Thoracic Surgeons that recommend broader application of concomitant SA

Coronary Revascularization With Single Versus Bilateral Mammary Arteries: Is It Time to Change?

BACKGROUND: Arterial conduits are preferred to venous conduits for coronary artery bypass grafting because of longer patency. A single internal mammary artery (SIMA) is used routinely. Bilateral internal mammary arteries (BIMA) are used less frequently. We sought to determine whether BIMA were superior to SIMA. METHODS: From our regional registry of consecutive open heart operations, we identified 47,984 patients who underwent isolated coronary artery bypass grafting from 1992 to 2014. Of the 1,482 BIMA patients, 1,297 were propensity matched to a cohort of SIMA patients. Short-term outcomes were compared using standard statistical techniques. Long-term survival was compared using Kaplan-Meier estimators and compared using a log-rank test. RESULTS: BIMA patients were younger and had fewer comorbid conditions than SIMA patients. After propensity weighting, BIMA and SIMA patients were well matched. There was no difference in in-hospital outcomes for BIMA versus SIMA patients for mortality (1.2% [n = 15] vs 0.8% [n = 10], p = 0.315), stroke (0.7% [n = 9] vs 0.7% [n = 9), p = 1.000), bleeding (2.2% [n = 28] vs 2.8% [n = 36], p = 0.311), or mediastinitis (0.8% [n = 10] vs 0.9% [n = 12], p = 0.667). The median follow-up was 12 years. Survival was better for BIMA than SIMA (adjusted hazard ratio, 0.79; 95% confidence interval, 0.69 to 0.91; p \u3c 0.001). Survival curves began to separate after 5 years. At 15 years, the absolute difference in survival was 8.4%. CONCLUSIONS: In a large regional experience, BIMA is associated with no upfront risk of adverse events and improved long-term survival compared with SIMA. Our results indicate that BIMA conduits should be considered more frequently during coronary artery bypass grafting due to their demonstrated survival advantage

Should Diabetes Be a Contraindication to Bilateral Internal Mammary Artery Grafting?

BACKGROUND: This study evaluates the influence of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting on postoperative morbidity and long-term survival among diabetic patients undergoing coronary artery bypass grafting (CABG). METHODS: A multicenter, retrospective analysis of 47,984 consecutive CABGs performed from 1992 to 2014 at 7 medical centers was conducted. Among the study population, 1,482 CABGs with BIMA were identified, and 1,297 BIMA patients were propensity-matched to 1,297 SIMA patients. The study cohort for this analysis, drawn from matched data, included 430 diabetic patients: 217 SIMA and 213 BIMA. The primary endpoint was long-term survival. Secondary endpoints included postoperative morbidity, length of stay, and in-hospital mortality. RESULTS: The median duration of follow-up was 9.3 (range, 4.3 to 13.9) years. Among propensity-matched diabetic patients, there was no significant difference in age, body mass index, or major baseline comorbidities. The groups were also well matched on the number of diseased coronary arteries and number of distal anastomoses performed. There was no difference in the rate of mediastinitis or sternal dehiscence (p = 0.503) or in-hospital mortality (p = 0.758) between groups. Both groups had a similar median length of stay of 5 (range, 4 to 7) days. Diabetic patients who received a BIMA had significantly improved long-term survival when compared with SIMA patients (hazard ratio 0.75 [95% confidence interval 0.57 to 0.98], p = 0.034). CONCLUSIONS: Among diabetics undergoing CABG, use of BIMA grafting does not result in increased in-hospital morbidity or mortality and confers a long-term survival advantage when compared with SIMA grafting. Thus, diabetic patients should be considered for BIMA grafting more frequently