Publications by authors named "Douglas R Johnston"

127 Publications

Outcomes of Open v. Endovascular Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms.

Ann Thorac Surg 2021 May 25. Epub 2021 May 25.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Open repair is the standard of care for patients with descending thoracic and thoracoabdominal aortic aneurysms. Although effective, surgery carries a high risk of morbidity and mortality. Endovascular stent-grafts were introduced to treat these aneurysms in patients considered too high risk for open repair. Early results are promising, but later results are incompletely known. Therefore, we sought to compare short- and intermediate-term outcomes of open versus endovascular repair for these aneurysms.

Methods: From 2000-2010, 1,053 patients underwent open (n=457) or endovascular (n=596) repair of descending thoracic and thoracoabdominal aortic aneurysms at Cleveland Clinic. To balance patient characteristics between these groups, propensity-score matching was performed, yielding 278 well-matched pairs (61% of possible pairs). Endpoints included short- and long-term outcomes.

Results: In matched patients, compared with endovascular stenting, open repair achieved similar in-hospital mortality (n=23/8.3% vs n=21/7.6%, P=.8) and occurrence of paralysis and stroke (n=10/3.6% vs n=6/2.2%, P=.3), despite longer postoperative stay (median 11 vs 6 days), more dialysis-dependent acute renal failure (n=24/8.6% vs n=9/3.3%, P=.008), and prolonged ventilation (n=106/46% vs n=17/6.3%, P<.0001). Open repair resulted in better 10-year survival than endovascular repair (52% vs 33%, P<.0001), and aortic reintervention was less frequent (4% vs 21%, P<.0001). Despite a decrease in the first postoperative year, average aneurysm size did not recover to normal range after endovascular stenting.

Conclusions: Open repair of descending thoracic and thoracoabdominal aneurysms can achieve acceptable short-term outcomes with better intermediate-term outcomes than endovascular repair.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.100DOI Listing
May 2021

Post-pump Aortic Insufficiency is Transient After Valve Replacement with a Novel Prosthesis.

J Am Soc Echocardiogr 2021 May 12. Epub 2021 May 12.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA; Aortic Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.

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http://dx.doi.org/10.1016/j.echo.2021.04.020DOI Listing
May 2021

Evolution of Recipient Characteristics Over 3 Decades and Impact on Survival After Lung Transplantation.

Transplantation 2021 Mar 18. Epub 2021 Mar 18.

1Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute 2 Department of Quantitative Health Sciences 3Departmet of Pulmonary Medicine, Respiratory Institute 4Department of Inflammation & Immunity, Lerner Research Institute.

Background: Lung transplantation (LTx) is a definitive treatment for end-stage lung disease. Herein, we reviewed our center experience over three decades to examine the evolution of recipient characteristics and contemporary predictors of survival for LTx.

Methods: We retrospectively reviewed the data of LTx procedures performed at our institution from 1/1990 to 1/2019 (n=1819). The cohort is divided into three eras; I: 1990-1998 (n=152), II: 1999-2008 (n=521), III: 2009-2018 (n=1146). Uni- and multivariate analyses of survival in era III were performed.

Results: Pulmonary fibrosis has become the leading indication for LTx (13% in Era I, 57% in Era III). Median recipient age increased (Era I: 46 years - Era III: 61 years) as well as intraoperative mechanical circulatory support (Era I: 0% - Era III: 6%). Higher lung allocation score (LAS) was associated with primary graft dysfunction (PGD) (p<0.0001), postoperative ECMO (p<0.0001), and in-hospital mortality (p=0.002). In Era III, hypoalbuminemia, thrombocytopenia, and high PGD grade were multivariate predictors of early mortality. The 5-year survival in Era II (55%) and III (55%) were superior to Era I (40%, p<0.001). Risk factors for late mortality in era III included recipient age, chronic allograft dysfunction, renal dysfunction, high MELD score, and single LTx.

Conclusions: In this longitudinal single-center study, recipient characteristics have evolved to include sicker patients with greater complexity of procedures and risk for postoperative complications but without significant impact on hospital mortality or long-term survival. With advancing surgical techniques and perioperative management, there is room for further progress in the field.Supplemental Visual Abstract; http://links.lww.com/TP/C191.
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http://dx.doi.org/10.1097/TP.0000000000003756DOI Listing
March 2021

Similar long-term survival after isolated bioprosthetic versus mechanical aortic valve replacement: A propensity-matched analysis.

J Thorac Cardiovasc Surg 2021 Jan 20. Epub 2021 Jan 20.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio. Electronic address:

Objectives: Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement.

Methods: From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients.

Results: Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P > .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P < .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] < .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group.

Conclusions: Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.
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http://dx.doi.org/10.1016/j.jtcvs.2020.11.181DOI Listing
January 2021

Modern practice and outcomes of reoperative cardiac surgery.

J Thorac Cardiovasc Surg 2021 Jan 23. Epub 2021 Jan 23.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

Objectives: To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest.

Methods: From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect.

Results: Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2).

Conclusions: Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.028DOI Listing
January 2021

Adjunctive endovascular balloon fracture fenestration for chronic aortic dissection.

J Thorac Cardiovasc Surg 2020 Oct 7. Epub 2020 Oct 7.

Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio;. Electronic address:

Objective: Positive remodeling after thoracic endovascular aortic repair (TEVAR) for chronic thoracic aortic dissection is variable due to incomplete distal seal and retrograde false lumen perfusion. We assessed the outcomes of adjunctive balloon fracture fenestration (BFF) during TEVAR in patients with chronic aortic dissection complicated by negative remodeling.

Methods: From June 2013 to January 2016, 49 patients with chronic aortic dissection complicated by aneurysm due to negative remodeling underwent TEVAR with BFF. Contrast-enhanced computed tomography was performed before discharge, at 3 to 6 months, and annually.

Results: Intraoperatively, endovascular stent graft expansion was achieved in all patients. There was 1 hospital death due to visceral malperfusion related to acute-on-chronic dissection noted before planned BFF. There were no occurrences of paraplegia, 3 patients had stroke, and 3 had acute renal failure. Survival at 1 year was 91%. Late reintervention for incomplete false lumen exclusion was required in 16 patients and freedom from reintervention was 75% at 1 year. Thirty-six patients (73.5%) had complete false lumen thrombosis through the treated segment. True lumen area increased following TEVAR with BFF and continued to incrementally expand with subsequent aortic remodeling at 1-year follow-up. Thirteen patients had positive remodeling, defined as thrombosis of false lumen, ≥10% decrease in aortic dimension, and ≥10% increase in true lumen diameter. Patients with positive remodeling had an average decrease of 11 mm in maximal aortic diameter at final follow-up.

Conclusions: BFF of chronic dissection membrane is a beneficial adjunct to TEVAR during short-term follow-up and may promote positive aortic remodeling and is worthy of further study.
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http://dx.doi.org/10.1016/j.jtcvs.2020.09.106DOI Listing
October 2020

Durability and Performance of 2298 Trifecta Aortic Valve Prostheses: A Propensity-Matched Analysis.

Ann Thorac Surg 2021 04 1;111(4):1198-1205. Epub 2020 Oct 1.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Reports of early failure of the Trifecta externally wrapped, bovine pericardial aortic valve prosthesis (Abbott Laboratories, Abbott Park, IL) raise concerns about its durability. This study evaluated the hemodynamic performance and explant of Trifecta valves compared with the PERIMOUNT bovine pericardial prosthesis (Edwards Lifesciences, Irvine, CA).

Methods: From October 2007 to July 2017, 2305 patients received a Trifecta bioprosthesis during aortic valve replacement at Cleveland Clinic. Trends in postoperative valve hemodynamics were assessed from 4971 transthoracic echocardiograms and valve explants by systemic follow-up. To compare outcomes, 2298 patients receiving a Trifecta valve were 1:1 propensity matched from 17,281 patients receiving a PERIMOUNT bioprosthesis.

Results: Mean age at implant was 69 years in both matched groups. Compared with PERIMOUNT valves, early transvalvular mean gradient of Trifecta valves was lower (11 vs 15 mm Hg at 1 year, P < .001); however, its longitudinal rate of rise was greater (P < .001), resulting in 5-year mean gradients of 17 vs 16 mm Hg, and more patients experienced severe aortic regurgitation (2.4% vs 0.81%; P < .001). At 5 years, 35 Trifecta valves had been explanted vs 14 PERIMOUNT valves; freedom from explant at 1, 3, and 5 years was 98.9%, 98.0%, and 95.9%, respectively, for the Trifecta group vs 99.3%, 99.0%, and 98.7% for the PERIMOUNT group (P < .001).

Conclusions: Compared with an older-generation internally mounted bovine pericardial valve, the Trifecta externally wrapped bioprosthesis exhibits superior early hemodynamic performance, but has a rapid increase in transvalvular gradient and more aortic regurgitation, with lower freedom from explant at 5 years. These findings raise concern regarding long-term Trifecta durability despite favorable early hemodynamics.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.040DOI Listing
April 2021

Performance and Durability of Cryopreserved Allograft Aortic Valve Replacements.

Ann Thorac Surg 2021 Jun 25;111(6):1893-1900. Epub 2020 Sep 25.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: The value of allografts for aortic root replacement is controversial, with recent concern about limited durability. Currently, we prefer allografts for invasive infective endocarditis. Purposes of this study were to assess allograft performance and durability in our cumulative experience with aortic allografts.

Methods: From January 1987 to January 2017, 2042 adults received 2110 aortic allograft root replacements at our institution: 986 (47%) for infective endocarditis (669 [68%] for prosthetic valve endocarditis) and 1124 (53%) for other indications. Mean recipient age was 54 ± 15 years, and mean allograft donor age was 35 ± 13 years. Follow-up was 85% complete and comprised 17,253 patient-years of data. Longitudinal allograft performance was extracted from 6339 available echocardiographic studies. Durability was assessed by explant for allograft structural failure.

Results: Allograft mean gradient at hospital discharge was 6 mm Hg and 9, 13, and 15 mm Hg at 5, 10, and 15 years post-implant, respectively. Severe aortic regurgitation was 0% at hospital discharge, but 14%, 25%, and 35% at 5, 10, and 15 years, respectively. A total of 405 allografts were explanted for structural failure, actuarially 2%, 14%, 34%, and 51% at 5, 10, 15, and 20 years, respectively. Risk factors for structural failure were younger recipient age, larger body surface area, hypertension, and thoracic aorta disease; donor factors were older age and larger allograft size. Implant for infective endocarditis was not associated with accelerated structural failure.

Conclusions: This study affirms allografts' long-term acceptable hemodynamic performance and durability. Concern about structural failure should not limit allograft use. Recipient hypertension, allograft size, and donor age are modifiable risk factors.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.033DOI Listing
June 2021

Effect of Dedicated In-Person Interpreter on Satisfaction and Efficiency in Otolaryngology Ambulatory Clinic.

Otolaryngol Head Neck Surg 2021 05 22;164(5):944-951. Epub 2020 Sep 22.

Division of Otolaryngology, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA.

Objective: In a large academic children's hospital ambulatory clinic, the increasing demand for Spanish interpretation exceeds the Interpreting Services Department capacity, necessitating telephone interpretation. By adding a dedicated Spanish interpreter in the otolaryngology clinic, we aimed to decrease visit times for Spanish-speaking patients and increase satisfaction. Additional aims explored if dedicated Spanish interpreters could increase patients seen per session.

Methods: A quality improvement initiative investigated baseline state compared to 2 tests of change using video interpretation and dedicated, in-person interpretation. Time permitting, interpreters contacted patients before the visit to decrease missed appointments and late arrivals. Measures included clinic visit times, late arrivals, missed appointments, and family/employee satisfaction scores. Actuarial statistics forecasted if on-site Spanish interpreters would affect patients seen per session and the potential addition of sessions.

Results: In-person interpretation reduced visit times for Spanish-speaking patients from 55 to 48 minutes ( = .01) and 57 to 48 minutes for all patients ( < .0001). Nearly 50% of video calls experienced technical difficulties. Families and employees preferred in-person over video and phone interpretation. No-show visits decreased by 25% and late arrivals by 17%.

Discussion: Implementing dedicated Spanish interpreters may increase productivity and enhance family experience.

Implications For Practice: Reducing patient visit time by 9 minutes permits 2 additional patients per clinic session (1560 visits, 390 surgeries per year). Applied institution-wide, the intervention could create 29% more capacity in the ambulatory schedule (31,000 additional visits) and reduce actuarial need for ambulatory sessions in the same clinic space.
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http://dx.doi.org/10.1177/0194599820957254DOI Listing
May 2021

Transoral Robotic Surgery Excision of Lingual Thyroglossal Duct Cysts Including the Central Hyoid Bone.

Laryngoscope 2021 04 21;131(4):E1345-E1348. Epub 2020 Sep 21.

Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.

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http://dx.doi.org/10.1002/lary.29100DOI Listing
April 2021

Outcomes of Early Coronary Angiography or Revascularization After Cardiac Surgery.

Ann Thorac Surg 2021 05 16;111(5):1494-1501. Epub 2020 Sep 16.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Early coronary ischemic events are uncommon after cardiac surgery, with little known about their management or associated outcomes. We evaluated clinical outcomes of patients undergoing coronary angiography ± percutaneous coronary intervention or redo coronary artery bypass grafting for suspected coronary ischemia within 3 weeks after index cardiac surgery.

Methods: This is a retrospective observational study based on data from 53,287 patients who underwent cardiac surgery at our institution (1996-2017); 180 patients (0.34%) satisfied the inclusion criteria. The primary outcome was 1-year all-cause mortality. Statistical evaluation involved χ, analysis of variance, Kaplan-Meier, and receiver operating characteristic curve analyses.

Results: Most coronary angiography ± percutaneous coronary intervention and redo coronary artery bypass grafting procedures occurred in the first 2 weeks after index cardiac surgery. Patients presenting with ST elevation myocardial infarction (STEMI)/non-STEMI had the lowest 1-year mortality (13.5%), followed by patients with ventricular tachycardia/fibrillation (28.1%), and patients with non-ventricular tachycardia/fibrillation arrest or hemodynamic instability alone the worst (38.6%) (χ = 17.3, P = .001). Peak troponin T level after cardiac surgery was strongly predictive of 1-year mortality (area under the curve, 0.74; 95% confidence interval, 0.65-0.84; P < .001) but did not predict the presence of coronary compromise. For acute graft failure, 1-year mortality was better with percutaneous coronary intervention (18.2%) than redo coronary artery bypass grafting (23.5%) or no indicated/feasible intervention (29.2%).

Conclusions: Although suspected myocardial ischemia requiring coronary angiography or intervention early after cardiac surgery was rare, mortality was high, particularly in presentations other than STEMI/non-STEMI. In patients with overt signs and symptoms of myocardial ischemia after index cardiac surgery, troponin T was not a reliable marker of underlying coronary or graft obstruction but was a robust predictor of 1-year mortality.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.113DOI Listing
May 2021

Aortic Valve Replacement in Young and Middle-Aged Adults: Current and Potential Roles of TAVR.

Ann Thorac Surg 2020 Aug 6. Epub 2020 Aug 6.

Division of Pediatric Cardiac Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Contemporary practice patterns and outcomes for aortic valve replacement (AVR) among young and middle-aged adults are unknown given guideline modifications for surgical AVR (SAVR) and increasing transcatheter AVR (TAVR) acceptance. This study describes SAVR and TAVR use and outcomes using The Society of Thoracic Surgeons (STS) National Databases.

Methods: Adults 18 to 55 years of age in the Congenital Heart Surgery Database (CHSD) and the Adult Cardiac Surgery Database (ACSD) who underwent SAVR or TAVR from 2013 to 2018 were included. Perioperative characteristics and early outcomes were described by valve type. Multivariable regression identified determinants of death, length of hospital stay, and a composite end point of renal failure, persistent neurologic deficit, readmission, and reoperation.

Results: The study analyzed 1580 unique CHSD and 44,173 ACSD operations, 16% of which were performed in patients with congenital heart disease. Valve use included the following: TAVR, 1%; mechanical, 42%; bioprosthetic, 55%; autograft, 0.6%; homograft, 1.2%; and Ozaki, 0.4%. Over time, TAVR volumes increased by 167%. The 30-day mortality was as follows: TAVR, 3.8%; mechanical, 3.2%; bioprosthetic, 3.7%; autograft, 0.6%; homograft, 9%; and Ozaki, 3.4%. Stroke rate was lower for isolated SAVR vs isolated TAVR (0.9% vs 2.4%; P = .002). In multivariable analyses, mortality risk was lower with mechanical valves, congenital morbidity risk was higher with TAVR, and length of stay was shorter with TAVR.

Conclusions: TAVR is increasingly used for adults younger than 55 years of age. Given the uniformly excellent results with SAVR, including both mortality and morbidity-particularly regarding stroke, our data favor SAVR in this population, but a prospective trial is needed. Ongoing efforts to harmonize variables and outcomes definitions between the ACSD and CHSD are valuable.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.180DOI Listing
August 2020

Aortic root replacement with bicuspid valve reimplantation: Are outcomes and valve durability comparable to those of tricuspid valve reimplantation?

J Thorac Cardiovasc Surg 2020 May 11. Epub 2020 May 11.

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Objectives: To assess intermediate-term outcomes of aortic root replacement with valve-sparing reimplantation of bicuspid aortic valves (BAV), compared with tricuspid aortic valves (TAV).

Methods: From January 2002 to July 2017, 92 adults underwent aortic root replacement with BAV reimplantation and 515 with TAV reimplantation at the Cleveland Clinic. Balancing-score matching based on 28 preoperative variables yielded 71 well-matched BAV and TAV pairs (77% of possible pairs) for comparison of postoperative mortality and morbidity, longitudinal echocardiogram data, aortic valve reoperation, and survival.

Results: In the BAV group, 1 hospital death occurred (1.1%); mortality among all reimplantations was 0.2%. Among matched patients, procedural morbidity was low and similar between BAV and TAV groups (1 stroke in TAV group; renal failure requiring dialysis, 1 patient each; red cell transfusion, 25% each). Five-year results: Severe aortic regurgitation was present in 7.4% of the BAV group and 2.9% of the TAV group (P = .7); 39% of BAV and 65% of TAV patients had none. Higher mean gradients (10 vs 7.4 mm Hg; P = .001) and left ventricular mass index (111 vs 101 g/m; P = .5) were present in BAV patients. Freedom from aortic valve reoperation was 94% in the BAV group and 98% in the TAV group (P = .10), and survival was 100% and 95%, respectively (P = .07).

Conclusions: Both BAV and TAV reimplantations can be performed with equal safety and good midterm outcomes; however, the constellation of higher gradients, less ventricular reverse remodeling, and more aortic valve reoperations with BAV reimplantations raises concerns requiring continued long-term surveillance.
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http://dx.doi.org/10.1016/j.jtcvs.2020.02.147DOI Listing
May 2020

Impact of Endovascular False Lumen Embolization on Thoracic Aortic Remodeling in Chronic Dissection.

Ann Thorac Surg 2021 02 7;111(2):495-501. Epub 2020 Jun 7.

Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Retrograde false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for chronic dissection is a mode of treatment failure. Thrombosis of the FL is associated with favorable reverse remodeling. Objectives are to describe FL embolization (FLE) strategy and assess aortic remodeling and survival.

Methods: From January 2009 to December 2017, 51 patients with chronic dissection underwent FLE, most after previous TEVAR. Devices included a combination of iliac plug (29 patients), coils (19 patients), or nitinol plug (3 patients). Computed tomography was performed before discharge, at 3 months, and annually (median follow-up 2 years [range, 1 month to 7 years]).

Results: After FLE, mean maximum aortic diameter decreased (64.2 ± 12 mm to 61.0 ± 13 mm; P = .03), true lumen diameter increased (24.7 ± 10 mm to 33.7 ± 8 mm; P < .001), and FL diameter decreased (36.7 ± 12 mm to 25.6 ± 15 mm, P < .001). For reverse remodeling, FL thrombosis with ≥10% decrease in diameter and ≥10% increase in true lumen diameter was achieved in 20 (39.2%; 16 primarily, 4 secondarily). Nine patients progressed after the first FLE: persistent FL flow with increase in aortic diameter and underwent repeat FLE with complete thrombosis (n = 4) or open thoracoabdominal completion (n = 5). A total of 26 patients had indeterminate response (FL thrombosis without change in maximum diameter), and none have required reoperation. Six patients had complete obliteration of the entire FL. At last follow-up, 42 (82%) patients were alive. Three deaths were related to aortic pathology.

Conclusions: FLE is an important endovascular adjunct to TEVAR promoting reverse aortic remodeling in select patients with chronic aortic dissection and persistent retrograde FL perfusion.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.093DOI Listing
February 2021

Access or excess? Examining the argument for regionalized cardiac care.

J Thorac Cardiovasc Surg 2020 09 29;160(3):813-819. Epub 2020 May 29.

Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.jtcvs.2019.12.125DOI Listing
September 2020

Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis.

J Surg Res 2020 10 7;254:1-6. Epub 2020 May 7.

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Little is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients.

Methods: From 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion.

Results: Two of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively.

Conclusions: Among patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.
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http://dx.doi.org/10.1016/j.jss.2020.03.069DOI Listing
October 2020

Commentary: Coronary artery bypass grafting as a subspecialty: Hype or reality.

J Thorac Cardiovasc Surg 2021 Jun 18;161(6):2136-2137. Epub 2020 Apr 18.

Department of Thoracic and Cardiovascular Surgery, Center for Coronary Revascularization, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.jtcvs.2020.04.013DOI Listing
June 2021

Intermediate-term outcomes of aortic valve replacement using a bioprosthesis with a novel tissue.

J Thorac Cardiovasc Surg 2020 Feb 21. Epub 2020 Feb 21.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Objectives: The COMMENCE trial was conducted to evaluate the safety and effectiveness of an aortic bioprosthesis with novel RESILIA tissue (Edwards Lifesciences, Irvine, Calif). Reports of early noncalcific valve failure resulting from thrombosis or leaflet tears in other valves warrant careful evaluation of early valve performance.

Methods: Patients underwent clinically indicated surgical aortic valve replacement with the Edwards Pericardial Aortic Bioprosthesis, Model 11000A (Edwards Lifesciences) in a prospective, multinational, multicenter (n = 27), single-arm, Food and Drug Administration Investigational Device Exemption trial. Events were adjudicated by an independent clinical events committee; echocardiograms were analyzed by an independent core laboratory.

Results: Between January 2013 and March 2016, 689 patients received the study valve. Mean age was 67.0 ± 11.6 years. Mean Society of Thoracic Surgeons predicted risk of mortality was 2.0% ± 1.8%. Follow-up duration was 3.7 ± 1.2 years, with a total of 2533 patient years of follow-up and a median follow-up of 4 years. Early all-cause mortality was 1.2%, thromboembolism 2.3%, all bleeding 1.0%, and major paravalvular leak 0.1%. One- and 4-year actuarial freedom from all-cause mortality was 97.7% (95% confidence interval, 96.5%-98.8%) and 91.9% (95% confidence interval, 89.7%-94.1%), respectively. At 4 years, New York Heart Association functional class improved compared with baseline in 63.0%, effective orifice area was 1.5 ± 0.5 cm, and mean gradient was 11.0 ± 5.6 mm Hg. Freedom from moderate or greater transvalvular insufficiency was 99.7%. There were no events of structural valve deterioration.

Conclusions: Safety and hemodynamic performance of this aortic bioprosthesis with RESILIA tissue at 4 years are favorable. This novel tissue does not appear to result in unexpected early thrombosis events or noncalcific structural valve deterioration.
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http://dx.doi.org/10.1016/j.jtcvs.2020.01.095DOI Listing
February 2020

Long-Term Outcomes in Patients With Mixed Aortic Valve Disease and Preserved Left Ventricular Ejection Fraction.

J Am Heart Assoc 2020 04 24;9(7):e014591. Epub 2020 Mar 24.

Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.

Background Concurrent presence of aortic stenosis and aortic regurgitation is termed mixed aortic valve disease (MAVD). Although multiple articles have addressed patients with "isolated" aortic stenosis or aortic regurgitation, the natural history, impact, and outcomes of MAVD are not well defined. Here, we evaluate long-term outcomes in patients with MAVD and cardiovascular adaptations to chronic MAVD. Methods and Results This observational cohort study evaluated 862 adult patients (56.8% male) with preserved left ventricular ejection fraction and at least moderate aortic regurgitation and moderate aortic stenosis. Primary outcome was all-cause mortality. Subgroup analysis was based on treatment modality (aortic valve replacement [AVR] versus medical management). A regression analysis of longitudinal echocardiographic parameters was performed to assess the natural history of MAVD. Mean age was 68±15 years, and mean left ventricular ejection fraction was 58±5%. At 4.6 years (25th-75th percentile range, 1.0-8.7), 58.6% of patients underwent an AVR and 48.8% patients died. In both unadjusted and adjusted Cox survival analysis, AVR was associated with improved survival (hazard ratio, 0.41; 95% CI, 0.34-0.51, <0.001). Impact of AVR persisted when stratifying the cohort by symptom status and baseline aortic valve area (log rank, <0.001 for both) and after propensity-score matching (hazard ratio, 0.40; 95% CI, 0.32-0.50; <0.001). In the longitudinal analysis, there were statistically significant changes over time in aortic valve peak gradient (<0.001) and aortic valve area (<0.001) and only mild increases in left ventricular end-diastolic (<0.007) and -systolic (<0.001) volumes. Conclusions MAVD confers a high risk of all-cause mortality. However, AVR significantly reduces this risk independent of aortic valve area, symptom status, and after controlling for confounding variables.
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http://dx.doi.org/10.1161/JAHA.119.014591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428636PMC
April 2020

Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting.

J Am Coll Cardiol 2020 01;75(3):258-268

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

Background: The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting.

Objectives: This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting.

Methods: From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important: >75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality.

Results: A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p < 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target-77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival.

Conclusions: In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.
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http://dx.doi.org/10.1016/j.jacc.2019.11.026DOI Listing
January 2020

Imaging-Guided Therapies for Pericardial Diseases.

JACC Cardiovasc Imaging 2020 06 13;13(6):1422-1437. Epub 2019 Nov 13.

Center for the Diagnosis and Treatment of Pericardial Diseases, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Frequently, multimodality imaging is indispensable in the care of patients with pericardial disease. With cardiac magnetic resonance imaging, pericardial inflammation can be characterized as acute, subacute, or chronic. This spectrum of inflammation is variably associated with reduced compliance of the pericardium, which may result in constrictive pathophysiology, typically well-defined with echocardiography. This interplay between inflammation and hemodynamics is often optimally characterized with multimodality imaging and has redefined the approach of pericardiologists to diagnose, prognosticate, and tailor individual therapies.
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http://dx.doi.org/10.1016/j.jcmg.2019.08.027DOI Listing
June 2020

Displacement of the Facial Nerve by Deep Parotid Lobe Lesions in the Pediatric Population.

Laryngoscope Investig Otolaryngol 2019 Oct 19;4(5):550-553. Epub 2019 Aug 19.

Division of Pediatric Otolaryngology-Head and Neck Surgery Ann & Robert H. Luire Children's Hospital of Chicago Chicago Illinois U.S.A.

Objectives: To describe and investigate facial nerve displacement in deep lobe parotid lesions in children and to determine clinical and radiographic predictors of abnormal facial nerve position.

Methods: Retrospective case review of children who underwent total parotidectomy for deep lobe parotid lesions at a tertiary care center between January 2014 and December 2017. Aberrant facial nerve trajectory was defined as ascension of the nerve at an angle of 45° or greater. Elongation was defined as the main trunk >2 cm in length. Patient demographics, radiographic, pathologic results, postoperative nerve weakness, and intraoperative nerve findings were collected. Wilcoxon rank-sum test and Fisher's exact test were used to assess the associations between variables of interest and facial nerve position.

Results: A total of 20 patients were included. The mean age was 7.7 ± 5 years. The most common pathologies were lymphatic malformation, pleomorphic adenoma, and first branchial cleft cyst. Twelve out of twenty (60.0%) patients had abnormal intraoperative facial nerve position. There was no significant difference in distribution of pathologies between those with or without an abnormal intraoperative nerve position ( = .41). Neither radiographic lesion size nor distance between the lesion and proximal portion of the facial nerve (mastoid tip) were associated with abnormal facial nerve position intraoperatively.

Conclusion: Pediatric deep lobe parotid lesions can displace the facial nerve and distort its anatomy in a posterior lateral direction, in approximately 60% of patients. Statistical analysis of increased numbers of patients to further define predictors of aberrant nerve course is warranted.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6793612PMC
October 2019

Outcomes of Patients With Mediastinal Radiation-Associated Mitral Valve Disease Undergoing Cardiac Surgery.

Circulation 2019 10 7;140(15):1288-1290. Epub 2019 Oct 7.

Center for Radiation Heart Disease, Heart and Vascular Institute, Cleveland Clinic, OH.

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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.040546DOI Listing
October 2019

Consequences of Delayed Chest Closure During Lung Transplantation.

Ann Thorac Surg 2020 01 14;109(1):277-284. Epub 2019 Sep 14.

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Delayed chest closure is commonly used for cardiac surgery. However, insufficient data exist to guide its management in immunosuppressed lung transplantation patients, with unclear long-term consequences.

Methods: We performed 769 lung transplantations between January 2009 and January 2016. Of these, 47 (6%) required delayed chest closure because of coagulopathy, respiratory intolerance, and hemodynamic instability. On multivariable analysis, risk factors for delayed chest closure included double-lung transplantation and longer ischemic times. To account for differences between the 2 groups, we performed propensity matching, generating 46 well-matched pairs.

Results: Among matched patients with appropriate antimicrobial prophylaxis, we found no difference in 30-day prevalence of pneumonia, empyema, Clostridium difficile, bloodstream, and deep wound infections. There was also no difference in 6-month composite infections. However, delayed chest closure patients received more transfusions within 5 days of transplantation (median, 7 vs 3 units; P < .001), had more intubations > 5 days (80% vs 41%, P < .001), had more severe primary graft dysfunction (39% vs 17%, P = .044), had a longer hospital stay (median, 61 vs 25 days; P < .001), and had worse pulmonary function tests 6 years after transplant (P = .019). Fortunately, estimated survival at 6 months, 1 year, and 5 years between delayed and primary chest closure groups was similar (82%, 76%, and 39% vs 84%, 75%, and 50%, respectively; P = .23).

Conclusions: Use of delayed chest closure does not yield more infections or worse long-term survival. However it may be associated with increased in-hospital morbidities and worse long-term pulmonary function.
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http://dx.doi.org/10.1016/j.athoracsur.2019.08.016DOI Listing
January 2020

Prevention, Diagnosis, and Management of Radiation-Associated Cardiac Disease: JACC Scientific Expert Panel.

J Am Coll Cardiol 2019 08;74(7):905-927

Department of Cardiothoracic Surgery, Center for Radiation Heart Disease, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

Radiation-associated cardiac disease, a heterogeneous and complex disease, manifests years or even decades following radiation exposure to the chest. It is associated with a significantly higher morbidity and mortality. Often, the presentation is vague and overlaps with many diseases, presenting unique diagnostic and management issues. As a result, a high index of suspicion followed by multimodality imaging is crucial, along with comprehensive screening to enable early detection. Timing of intervention should be carefully considered in these patients, because surgery is often complex with an emerging role of percutaneous interventions.
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http://dx.doi.org/10.1016/j.jacc.2019.07.006DOI Listing
August 2019

Differentiating Constriction from Restriction (from the Mayo Clinic Echocardiographic Criteria).

Am J Cardiol 2019 09 25;124(6):932-938. Epub 2019 Jun 25.

Center for the Diagnosis and Treatment of Pericardial Diseases, Heart and Vascular Institute, Cardiovascular Section, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Constrictive Pericarditis (CP) is a curable and reversible form of severe diastolic heart failure. We aimed to investigate the diagnostic accuracy of published echocardiographic Mayo Clinic Criteria in differentiating 107 patients with surgically proven CP from 30 patients with restrictive cardiomyopathy due to cardiac Amyloidosis. Five principal echocardiographic and Doppler variables were remeasured on preoperative transthoracic echocardiogram namely (1) respiration-related ventricular septal shift; (2) respiratory variation in mitral inflow E pulsed Doppler velocity; 3) tissue Doppler medial mitral annular e' velocity; (4) ratio of medial mitral annular e' to lateral mitral annular e' velocity; and 5) hepatic vein (HV) pulsed Doppler diastolic flow reversal ratio. Etiology of CP included viral/idiopathic or autoimmune (75%), postcardiac surgery (13%) and postradiation (7%). Univariate logistic regression analysis showed that (1) respiration related ventricular septal shift, (2) percentage change in Mitral E velocity, (3) medial e' velocity ≥9 cm/sec, (4) medial e'/lateral e' ratio ≥0.91, (5) HV diastolic reversal ratio ≥0.79 were associated with the diagnosis of CP. Multivariable logistic regression analyses showed that medial e' velocity ≥9 cm/s was independently associated with the diagnosis of CP. Respiration related ventricular septal shift had the highest sensitivity, whereas medial e' velocity ≥9 cm/s has the highest specificity to diagnose CP (Areas under curves 0.99, p 0.001). Combining respiration related ventricular septal shift with medial e' velocity ≥9 cm/s gave a desirable sensitivity (80%) and specificity (92%). Adding reversal ratio to this combination further increased the specificity (97%) but dropped the sensitivity (70%) to diagnose CP.
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http://dx.doi.org/10.1016/j.amjcard.2019.06.002DOI Listing
September 2019

Risk of adding prophylactic aorta replacement to a cardiac operation.

J Thorac Cardiovasc Surg 2020 05 18;159(5):1669-1678.e10. Epub 2019 May 18.

Aorta Center, Heart and Vascular Institute, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio.

Objective: The study objective was to determine whether adding prophylactic aorta replacement increases the risk of a cardiac operation when cardiac rather than aortic disease is the primary indication for operation.

Methods: Patients undergoing cardiac operations with aorta replacement (cardioaortic group), with or without circulatory arrest, were propensity matched to identify patients whose combined operation was not primarily indicated by aortic disease (n = 684). These patients were further propensity matched without accounting for thoracic-aortic measurements to patients undergoing cardiac operations without aorta replacement (cardiac-surgery only group), 647 pairs, for comparing outcomes.

Results: Most (n = 431/503 [86%]) propensity-matched patients undergoing cardioaortic operations had ascending aorta dilatation with a maximum aortic diameter of less than 5.5 cm. There was no evidence of an incremental increase in risk of in-hospital stroke (cardioaortic, n = 9/1.4% vs cardiac only, n = 7/1.1%; P = .6) or mortality (cardioaortic, n = 6/0.93% vs cardiac only, n = 3/0.46%; P = .5). Unmatched patients undergoing concomitant aortic surgery had advanced aortic disease distal to the ascending aorta (arch, 3.8 ± 0.98 cm vs 3.2 ± 0.51 cm; descending, 4.4 ± 1.7 cm vs 3.2 ± 0.99 cm) as the primary indication for their operation and had a high occurrence of in-hospital stroke (6.5% vs 1.5%, P = .0007) and death (7% vs 1.2%, P = .0001).

Conclusions: Prophylactic aorta replacement can be safely performed during a cardioaortic operation, without added penalty, when aortic disease is less severe and not the primary indication for surgery. Risks after an aorta replacement combined with cardiac surgery can be substantial, however, when advanced aortic disease is the primary indication for operation. These distinctive risks should be taken into consideration at the time of surgical decision-making.
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http://dx.doi.org/10.1016/j.jtcvs.2019.05.001DOI Listing
May 2020

Radiation-Associated Cardiac Disease: More Complicated Than Just Transcatheter Replacement of the Aortic Valve.

Cardiovasc Revasc Med 2019 05;20(5):369-370

From the Center of Radiation Heart Disease and the Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH. Electronic address:

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http://dx.doi.org/10.1016/j.carrev.2019.03.015DOI Listing
May 2019

Differences in management outcome for first branchial cleft anomalies: A comparison of infants and toddlers to older children.

Int J Pediatr Otorhinolaryngol 2019 Jul 11;122:161-164. Epub 2019 Apr 11.

Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Otolaryngology, McGaw Medical Center of Northwestern University, Chicago, IL, USA.

Objective: First branchial cleft anomalies (FBCAs) are rare and often misdiagnosed, which can delay proper management and increase surgical risks. Complete excision often requires parotidectomy with facial nerve dissection. The literature reports that younger patients more often have lesions deep to the nerve with higher rates of nerve injury. We hypothesized that the rate of nerve injury and complications in children with FBCAs was not different in those ≤2 years of age compared to those >2 years of age.

Methods: Retrospective review of pediatric patients who underwent resection of histopathologically confirmed FBCAs between 2007 and 2017 at a tertiary care, pediatric hospital. Presenting symptoms, lesion classification, prior procedures, imaging techniques, extent of surgery performed, facial nerve position, and complications were reviewed and compared between patients ≤2 years of age and >2 years of age at time of surgery.

Results: 43 cases of FBCAs were included in the study: 12 in the younger group and 31 in the older group. There was no difference between groups regarding the presenting symptoms, gender breakdown, lesion classification, prior procedures performed, or extent of surgery. Lesions were more commonly deep to or running between branches of the facial nerve in the younger group (33.3% vs 9.7%, p = .0496). Rates of postoperative complications and facial nerve weakness were comparable between the younger and older groups (8.3% vs 25.8%, p = .206; 25.0% vs 16.1%, p = .503). In combining the age groups, FBCAs located deep to the facial nerve had increased risk of nerve weakness postoperatively (RR 7.2) and those with a history of prior incision and drainage or resection had increased risk of postoperative complications (RR 2.36). Imaging was obtained on all subjects with accuracy rates of 80-100%.

Conclusion: Presenting characteristics of FBCAs in patients ≤2 years of age and >2 years of age are comparable, but lesions in younger subjects had a greater likelihood of being deep to or coursing between branches of the facial nerve. However, the rates of facial nerve injury and postoperative complications are comparable in younger and older children, owing likely to accurate preoperative imaging and appropriate surgical planning.
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http://dx.doi.org/10.1016/j.ijporl.2019.04.009DOI Listing
July 2019