J. Michael DiMaio M.D.

Baxter, R. D., S. K. Hansen, C. E. Gable, J. M. DiMaio, W. P. Shutze and D. R. Gable (2020). “Outcomes of Open versus Percutaneous Access for Patients Enrolled in the GREAT Registry.” Ann Vasc Surg Jun 27;S0890-5096(20)30534-3. [Epub ahead of print.].

Full text of this article.

BACKGROUND: Arterial access and device delivery in endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have evolved from open femoral or iliac artery exposure to selective percutaneous arterial access. Although regional application of percutaneous access for these two procedures varies widely, the use of this technique continues to increase. [1,2] Currently, differences in the use of percutaneous access between EVAR and TEVAR have not been well explored. The Gore Global Registry for Endovascular Aortic Treatment (GREAT) registry collected relevant data for evaluation of these issues as well as the comparative results between open and percutaneous approaches in regards to complication rates and length of stay. METHODS: This study was performed via a retrospective review of patients from the GREAT registry (Clinicaltrials.gov no. NCT01658787). The primary variable of this study was access site complications including postoperative hematoma, vessel dissection, and pseudoaneurysm. Patients were categorized by abdominal (EVAR) and thoracic (TEVAR) aortic procedures using percutaneous-only, cutdown-only, and combined vascular access techniques for a total of 6 groups. Standard statistical methodology was used to perform single- and multi-variable analysis of a variety of covariates including length of stay (LOS), geographical location of procedure, procedural success rate and access sheath size. RESULTS: Of 4,781 patients from the GREAT registry, 3,837 (80.3%) underwent EVAR and 944 (19.7%) underwent TEVAR with percutaneous-only access techniques being used in 2,017 (42.2%) and cutdown-only in 2,446 (51.2%). There was variable application of percutaneous access by geographic region with Australia and New Zealand using this technique more frequently and Brazil using percutaneous access the least. No significant difference in the rate of access site complications were detected between the 6 groups of patients in the study; however, significantly lower rates of access site complications were associated with percutaneous-only compared with both cutdown-only and combined techniques (p=0.03). Also associated with significantly higher rates of access site complications was longer lengths of stay (p<0.01). Average LOS was 5.2 days and was higher in the TEVAR group (10.1 days) compared to EVAR (4.0 days, p<0.05). Increased sheath size does not appear to increase the risk of access site complication. CONCLUSIONS: There was no significant difference found in the complication rate between percutaneous and cutdown access techniques. This analysis demonstrates that percutaneous-only access is safe, has low complication rates, and has lower LOS compared to open access or combined access techniques.

Khan, Z., M. Hamandi, H. Khan, J. M. DiMaio and M. Evans (2020). “Convergent epicardial-endocardial ablation for treatment of long-standing persistent atrial fibrillation: A review of literature.” J Card Surg Apr 25. [Epub ahead of print].

Full text of this article.

BACKGROUND AND AIM OF STUDY: The convergent procedure (CVP) is a hybrid ablation technique via a subxiphoid incision that has recently emerged as a treatment option for non-paroxysmal atrial fibrillation (npAF). By combining endocardial and epicardial ablation into a simultaneous or staged procedure, the pulmonary vein and posterior left atrium can be isolated with transmural lesion sets while minimizing the risk of proarrhythmic gaps that are a known limitation with endocardial linear lesion sets. We reviewed the 12-month outcomes in patients who underwent CVP compared to those who underwent endocardial catheter ablation (CA) and surgical ablation (SA). METHODS: A literature search was conducted using the PubMed database for publications related to CVP. Selected studies included detailed 12-month follow-up of patients, patient characteristics, periprocedural complications, use of antiarrhythmic drugs (AADs), and monitoring method. RESULTS: Five studies with 340 patients who underwent CVP between January 2009 and March 2017 were selected for this review. A total of 8.5% of patients had paroxysmal AF (pAF), 42.2% had persistent AF (peAF), and 49.1% had long-standing persistent AF (lspAF). At 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs. The overall complication rate was 10%. CONCLUSION: CVP had better 1-year efficacy in eliminating AF when compared to CA. However, SA, specifically the Cox Maze IV, had lower rates of AF recurrence in the npAF patient population. Despite its promising 1-year efficacy rates, the periprocedural complication rate for CVP was significantly higher than both CA and SA.

Baxter, R. D., J. I. Fann, J. M. DiMaio and K. Lobdell (2020). “Digital Health Primer for Cardiothoracic Surgeons.” Ann Thorac Surg pii: S0003-4975(20)30504-X. [Epub ahead of print].

Full text of this article.

The burgeoning demands for quality, safety, and value in cardiothoracic surgery, in combination with the advancement and acceleration of digital health solutions and information technology, provide a unique opportunity to simultaneously improve efficiency and effectiveness in cardiothoracic surgery. This primer on digital health will explore and review data integration, data processing, complex modeling, telehealth with remote monitoring, and cybersecurity as they shape the future of cardiothoracic surgery.

Iribarne, A., S. Pan, J. N. McCullough, J. P. Mathew, J. Hung, X. Zeng, P. Voisine, P. T. O’Gara, N. M. Sledz, A. C. Gelijns, W. C. Taddei-Peters, S. R. Messe, A. J. Moskowitz, V. H. Thourani, M. Argenziano, M. A. Groh, G. Giustino, J. R. Overbey, J. M. DiMaio and P. K. Smith (2020). “Impact of Aortic Atherosclerosis Burden on Outcomes of Surgical Aortic Valve Replacement.” Ann Thorac Surg 109(2): 465-471.

Full text of this article.

BACKGROUND: Epiaortic ultrasound detects and localizes ascending aortic atherosclerosis. In this analysis we investigated the association between epiaortic ultrasound-based atheroma grade during surgical aortic valve replacement (SAVR) and perioperative adverse outcomes. METHODS: SAVR patients in a randomized trial of 2 embolic protection devices underwent a protocol-defined 5-view epiaortic ultrasound read at a core laboratory. Aortic atherosclerosis was quantified with the Katz atheroma grade, and patients were categorized as mild (grade I-II) or moderate/severe (grade III-V). Multivariable logistic regression was used to estimate associations between atheroma grade and adverse outcomes, including death, clinically apparent stroke, cerebral infarction on diffusion-weighted magnetic resonance imaging, delirium, and acute kidney injury (AKI) by 7 and 30 days. RESULTS: Precannulation epiaortic ultrasound data were available for 326 of 383 randomized patients (85.1%). Of these, 106 (32.5%) had moderate/severe Katz atheroma grade at any segment of the ascending aorta. Although differences in the composite of death, stroke, or cerebral infarction on diffusion-weighted magnetic resonance imaging by 7 days were not statistically significant, moderate/severe atheroma grade was associated with a greater risk of AKI by 7 days (adjusted odds ratio, 2.63; 95% confidence interval, 1.24-5.58; P = .01). At 30 days, patients with moderate/severe atheroma grade had a greater risk of death, stroke, or AKI (adjusted odds ratio, 1.97; 95% confidence interval, 1.04-3.71; P = .04). CONCLUSIONS: Moderate/severe aortic atherosclerosis was associated with an increased risk of adverse events after SAVR. Epiaortic ultrasound may serve as a useful adjunct for identifying patients who may benefit from strategies to reduce atheroembolic complications during SAVR.

Lanfear, A. T., M. Hamandi, J. Fan, J. M. DiMaio and T. J. George (2020). “Trends in HeartMate 3: What we know so far.” J Card Surg 35(1): 180-187.

Full text of this article.

BACKGROUND: The HeartMate 3 left ventricular assist device (LVAD) is a novel, intrapericardial, centrifugal-flow pump with a fully magnetically-levitated rotor designed to provide hemodynamic support in patients with end-stage heart failure. Unique aspects of this LVAD have allowed for improved hemocompatibility and the development of minimally-invasive implantation techniques. METHODS: The PubMed, EMBASE, and Google Scholar databases were searched for publications relating to the HeartMate 3 device, with a focus on hemocompatibility related outcomes, anticoagulation management, and surgical techniques. RESULTS: Nine articles analyzing hemocompatibility related outcomes from two clinical trials, two clinical studies, and one registry series were identified. CONCLUSION: HeartMate 3 has reduced the rate of disabling stroke and pump thrombosis. However, despite increased hemocompatibility due to specialized design features, the residual risk of both surgical, and gastrointestinal bleeding remains a major adverse outcome. Different anticoagulation management and surgical techniques have been evaluated to address the remaining complications.