J. Michael DiMaio M.D.

Hamandi, M., A. T. Lanfear, J. Fan, M. L. Bolin, J. M. DiMaio, R. L. Smith and C. Dib (2019). “Incidental finding of giant coronary artery aneurysm.” J Card Surg Nov 25. [Epub ahead of print].

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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. (Full text of this image study.)

Baxter, R. D., J. J. Squiers and J. M. DiMaio (2019). “Commentary: Off-Pump Mitral Repair-Augmenting the Future.” J Thorac Cardiovasc Surg 158(4): e137.

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Functional mitral valve regurgitation continues to greatly increase morbidity and mortality of patients with ischemic cardiac disease. Medical management of mitral regurgitation for this condition can be effective when no other options exist; however, surgical treatment of mitral valve dysfunction for reduction of valvular regurgitation has been shown to increase both quality of life and overall survival in these patients. Operative interventions in this patient population continue to be challenging as a result of decreased physiologic reserve and increased risk of perioperative complications and mortality. In this issue of the Journal, Salizzoni and colleagues describe such a patient in their case report. Repair of this patient’s mitral valve would be complex because of its severe dysfunction and his challenging underlying comorbidities. Traditionally, surgical intervention for this patient could be considered prohibitively risky by many centers. The innovative technique described in this case report, however, offers an interesting approach to this problem. Emerging technologies allow mitral annuloplasty, leaflet edge fixation, and even leaflet tethering in a beating heart without the need for bypass. The most recent innovation—leaflet fixation—has shown great promise in this setting. Currently, however, these options are limited by mitral leaflet and annulus anatomy. Furthermore, a combination of surgical repair options is often needed in this population because of the complex nature of mitral valve anatomy. The technique described in this report, which allowed adequate repair of the mitral valve by leaflet augmentation on a beating heart free of cardiopulmonary bypass, has never been previously described. Proper use of mitral augmentation patches can be challenging for even experienced cardiac surgeons in an on-pump, cardiac arrest scenario. The willingness of the surgeons even to consider performing this procedure on a beating heart is an example of the mindset that has pushed cardiac surgery forward in patient care and technical advancement. The patient described in this case report, a 76-year-old man with significant congestive heart failure and history of multiple coronary artery bypass, is also to be commended. Although he was at high risk in undergoing surgical intervention, he was willing to proceed with a procedure that had never before been performed in a human being. Not only does this reflect his strong desire to alleviate his life-altering symptoms, it also highlights his faith in the surgical team caring for him. His consent to proceed was an essential part in pioneering these new care techniques for other patients with similar pathology. This report describes an innovative surgical technique that may warrant further investigation as we progress from traditional valvular augmentation procedures to minimally invasive techniques. Ongoing development may lead to a method of augmenting valvular tissue through completely endovascular methods and further increase available options for high-risk patients to receive optimal cardiac repair. (Excerpt from text, p. e137; no abstract available.)

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 (2019). “Impact of Aortic Atherosclerosis Burden on Outcomes of Surgical Aortic Valve Replacement.” Ann Thorac Surg Aug 7. [Epub ahead of print].

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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 two embolic protection devices underwent a protocol-defined 5-view epiaortic ultrasound read at a core-laboratory. Aortic atherosclerosis was quantified with Katz atheroma grade and patients were categorized into mild (grade I-II) versus 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 (DW-MRI), delirium, and acute kidney injury (AKI) by 7 and 30 days. RESULTS: Of the 383 randomized patients, 326 (85.1%) had pre-cannulation epiaortic ultrasound data available. Of these, 106 (32.5%) had moderate/severe Katz atheroma grade at any segment of the ascending aorta. While there were no significant differences in the composite of death, stroke or cerebral infarction on DW-MRI by 7 days, moderate/severe atheroma grade was associated with a greater risk of AKI by 7 days (adjusted odds ratio [OR]: 2.63; 95% confidence interval [CI]: 1.24-5.58; p=0.01). At 30 days, patients with moderate/severe atheroma grade had a greater risk of death, stroke or AKI (adjusted OR: 1.97; 95%CI: 1.04-3.71; p=0.04). CONCLUSIONS: Moderate/severe aortic atherosclerosis was associated with an increased risk of adverse events following SAVR. Epiaortic ultrasound may serve as a useful adjunct for identifying patients who may benefit from strategies to reduce atheroembolic complications during SAVR.

Hamandi, M., R. L. Smith, W. H. Ryan, P. A. Grayburn, A. Vasudevan, T. J. George, J. M. DiMaio, K. A. Hutcheson, W. Brinkman, M. Szerlip, D. O. Moore and M. J. Mack (2019). “Outcomes of Isolated Tricuspid Valve Surgery Have Improved in the Modern Era.” Ann Thorac Surg 108(1): 11-15.

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BACKGROUND: Surgery for isolated tricuspid valve (TV) disease remains relatively infrequent because of significant patient comorbidities and poor surgical outcomes. This study reviewed the experience with isolated TV surgery in the current era to determine whether outcomes have improved. METHODS: From 2007 through 2017, 685 TV operations were performed in a single institution, of which 95 (13.9%) operations were isolated TV surgery. Patients were analyzed for disease origin, risk factors, operative mortality and morbidity, and long-term survival. RESULTS: A total of 95 patients underwent isolated TV surgery, an average of 9 patients per year increasing from an average of 5 per year to 15 per year during the study period. Surgery was reoperative in 41% (38 of 95) of patients, including 11.6% (11 of 95) with prior coronary artery bypass grafting and 29.4% (28 of 95) with prior valve surgery (9 TV, 11 mitral, 2 aortic, 5 mitral and aortic, and 1 mitral and TV). Repair was performed in 71.6% (68 of 95) of patients, and replacement was performed in 28.4% (27 of 95). Operative mortality was 3.2% (3 of 95), with no mortality in the most recent 73 patients over the last 6 years. Stroke occurred in 2.1% (2 of 95) of patients, acute kidney injury requiring dialysis in 5.3% (5 of 95), and the need for new permanent pacemaker in 16.8% (16 of 95). CONCLUSIONS: In the current era with careful patient selection and periprocedural management, isolated TV surgery can be performed with lower morbidity and mortality than has traditionally been reported with good long-term survival. These outcomes can also serve as a benchmark for catheter-based TV intervention outcomes.

Hamandi, M., R. L. Smith, W. H. Ryan, P. A. Grayburn, A. Vasudevan, T. J. George, J. M. DiMaio, K. A. Hutcheson, W. Brinkman, M. Szerlip, D. O. Moore and M. J. Mack (2019). “Outcomes of Isolated Tricuspid Valve Surgery Have Improved in the Modern Era.” Ann Thorac Surg Apr 2. [Epub ahead of print].

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BACKGROUND: Surgery for isolated tricuspid valve (TV) disease remains relatively infrequent due to significant patient comorbidities and poor surgical outcomes. We reviewed our experience with isolated TV surgery in the current era to determine if outcomes have improved. METHODS: From 2007 through 2017, 685 TV operations were performed in a single institution of which 95 (13.9%) were isolated TV surgery. Patients were analyzed for disease etiology, risk factors, operative mortality and morbidity and long term survival. RESULTS: 95 patients underwent isolated TV surgery, an average of 9 patients/year increasing from an average of 5/year to 15/year during the study period. Surgery was reoperative in 41% (38/95), including 11.6% (11/95) with prior CABG and 29.4% (28/95) with prior valve surgery (9 tricuspid, 11 mitral, 2 aortic, 5 mitral/aortic and 1 mitral/tricuspid).Repair was performed in 71.6% (68/95) and replacement in 28.4% (27/95). Operative mortality was 3.2% (3/95) with no mortality in the most recent 73 patients over the last 6 years. Stroke occurred in 2.1% (2/95), acute kidney injury requiring dialysis in 5.3% (5/95) and need for new permanent pacemaker in 16.8% (16/95). CONCLUSIONS: In the current era with careful patient selection and periprocedural management, isolated TV surgery can be performed with lower morbidity and mortality than has traditionally been reported with good long term survival. These outcomes can also serve as a benchmark for catheter-based tricuspid valve intervention outcomes.