J. Michael DiMaio M.D.

Hamandi, M., A. T. Lanfear, J. Fan, M. L. Bolin, J. M. DiMaio, R. L. Smith and C. Dib (2020). “Incidental finding of giant coronary artery aneurysm.” J Card Surg 35(1): 200-201.

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A 58‐year‐old asymptomatic man presented to our institution after a routine cardiac computed tomography (CT) for calcium scoring. He did not have any history of connective tissue disorders or Kawasaki disease. CT angiogram confirmed the presence of a coronary artery aneurysm (CAA) measuring 10.3 × 6.8 cm arising from the right coronary artery (RCA) with true lumen enhancement. The rest of the aneurysm was thrombosed, and distal calcification of the RCA was also noted. Management for patients with CAA is not standardized, as CAAs appear in only 0.3% to 5.3% of patients undergoing coronary angiographies, while “giant” CAAs (>5 cm) appear in less than 0.02%. Surgical or percutaneous intervention and antiplatelet/anticoagulation therapy are commonly reported. Due to the rarity of giant coronary aneurysms, there is no standardized management strategy supported by controlled trials. Data assessing the risk of mortality associated with these management options is sparse. The patient was referred for aneurysm ligation with distal bypass grafting due to the size and potential high risk of rupture and the risk of distal embolization which can result in myocardial ischemia or infarction. His perioperative risk of mortality and morbidity was deemed to be extremely low. Following the median sternotomy, the aneurysm was opened and the large orifice of the main right coronary artery was noted. The right coronary ostium was ligated and the old mural thrombus within the aneurysm was removed. The patient underwent coronary artery bypass grafting. The clinical course was uneventful and he was discharged on postoperative day 4. In conclusion, the management of a giant coronary artery aneurysm should be guided by the patient’s clinical presentation and perioperative risk, the size of the aneurysm, and the final decision should be made by an experienced Heart Team approach. (Excerpt from text of this image study, p. 200-201; no abstract available.)

Baxter, R., J. Squiers, W. Conner, M. Kent, J. Fann, K. Lobdell and J. M. DiMaio (2019). “Enhanced Recovery After Surgery: A Narrative Review of its Application in Cardiac Surgery.” Ann Thorac Surg Dec 23. [Epub ahead of print].

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BACKGROUND: Enhanced recovery after surgery (ERAS) is a perioperative patient management strategy that is being adopted rapidly across surgical specialties worldwide. Components of ERAS work collaboratively throughout the perioperative course to achieve significant benefits for both the patient and the entire healthcare system. The use of ERAS in cardiac surgery (ERAS-C) could lead to similar improvements, but currently use of ERAS-C programs are lacking and not well-defined. METHODS: A search of the literature was performed of the Medline database to capture relevant studies discussing enhanced recovery after cardiac surgery. Key concepts were extracted from these articles and grouped according to appropriate perioperative stages. Supporting literature was also included briefly discussing the historical progression of cardiac surgery to enhanced recovery pathways, potential limitations to these pathways in cardiac surgery, and the first studies evaluating he use of an ERAS program with cardiac surgery patients. RESULTS: Initial results of ERAS-C studies have shown similar benefits to those of other surgical fields including decreased hospital and intensive care unit lengths of stay (1-4 days and 4-20 hours, respectively, improved perioperative pain control (25-60% decreased opioid usage), and improvements in early postoperative mobility and oral diets. Results especially beneficial to cardiac surgery have also been reported such as an 8-14% decreased incidence of postoperative atrial fibrillation. CONCLUSIONS: This manuscript aims to present pertinent current research related to the implementation of ERAS programs in the field of cardiac surgery and provide a call to action for further investigation and adaption of ERAS in cardiac surgery.

Squiers, J., H. Baumgarten, G. Filardo, D. Sass, B. Pollock, J. Edgerton, R. Marcel, J. M. DiMaio and R. L. Smith (2019). “Prospective Evaluation of a Blood Transfusion Protocol for Patients Undergoing Cardiac Surgery.” Ann Thorac Surg Nov 23. [Epub ahead of print].

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BACKGROUND: The Society of Thoracic Surgeons clinical practice guidelines recommend the creation of an interdisciplinary blood management team to implement protocols for improved blood transfusion practices. We report our center’s prospective evaluation of a blood transfusion protocol. METHODS: An interdisciplinary blood management team developed protocols for transfusion of packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. The protocols were prospectively evaluated by tracking transfusions administered to consecutive patients undergoing cardiac surgery, and the primary outcome of interest was the mean number of adjusted units of blood product transfused per patient. Protocol implementation phases were separated by washout phases to control for a potential Hawthorne effect associated with protocol implementation. Protocol compliance was also assessed. RESULTS: A total of 1441 patients underwent cardiac surgery during the 16-month study period. Although there was no statistically significant reduction in transfusions with an unadjusted analysis, there was a significant trend towards reduction of mean adjusted total units transfused per patient over the course of the study period (p<0.001). The mean adjusted total units transfused per patient were significantly less during the second washout phase (2.8 units, 95%CI 2.3-3.3) and second protocol phase (2.8 units, 95%CI 2.32-3.27) as compared to the initial baseline survey phase (3.6 units, 95%CI 3.1-4.1; p<0.05 for both comparisons). Only 55.2% of all units were transfused in compliance to the implemented protocols: platelets (46.8%), cryoprecipitate (32.1%), packed red blood cells (60.7%), and fresh frozen plasma (53.6%). CONCLUSIONS: During a prospective evaluation of blood transfusion protocols, a risk-adjusted analysis demonstrated a reduction in transfusions despite poor protocol compliance.

Lanfear, A. T., M. Hamandi, J. Fan, J. M. DiMaio and T. J. George (2019). “Trends in HeartMate 3: What we know so far.” J Card Surg Nov 6. [Epub ahead of print].

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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.

Hebeler, K. R., G. Filardo and J. M. DiMaio (2019). “Serum albumin and 1-year mortality in patients with transcatheter aortic valve replacement therapy (Reply).” Ann Thorac Surg Nov 28. [Epub ahead of print].

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We thank Dr. Kawada for the comments related to our study. The aim of our study was to assess the predictive ability of combining widely used frailty markers and sarcopenia measurements with the STS-PROM for 1-year mortality after TAVR and not to make inference on the magnitude of single point estimates. We agree that the relatively small number of events would have limited this latter analysis but this was beyond the purpose of our study. Nonetheless, the very large p-values estimated for all frailty markers (with the exception of albumin) [gait speed (Model 3: 0.54, Model 4: 0.59), grip strength (Model 3: 0.24, Model 4: 0.13), Katz ADL (Model 3: 0.43, Model 4: 0.43), and psoas muscle area (Model 4: 0.53)] suggest that a higher number of events would have not affected our results and conclusions regarding the poor prediction of these markers for 1-year mortality after TAVR. Likewise, we agree that the area under the curve of model 4 is not very high but again, the goal of the study was to present the predictive ability of combining widely used frailty markers and sarcopenia measurements with the STS-PROM for 1-year mortality. In fact, we stated in the conclusion of our manuscript that “…commonly used pre-TAVR risk assessments are poorly predictive of 1-year mortality.” In summary, we are confident that albumin was the only frailty marker that was associated with higher mortality. Future studies should investigate whether optimization of nutritional status can improve outcomes after TAVR. (Text of authors’ response to comments on their article, Hebeler KR, Baumgarten H, Squiers JJ, et al. “Albumin is predictive of 1-year mortality after transcatheter aortic valve replacement.” Ann Thorac Surg 2018;106:1302-7.)