Publications by authors named "Faisal G Bakaeen"

199 Publications

Outcomes and Role of Peripheral Revascularization in Type A Aortic Dissection (TAAD) Presenting with Acute Lower Extremity Ischemia.

J Vasc Surg 2021 Sep 6. Epub 2021 Sep 6.

Division of Vascular & Endovascular Surgery, University of Virginia, Charlottesville, VA 22908; Aortic Center, University of Virginia Medical Center, Charlottesville, VA 22908. Electronic address:

Objective: Limited data exists on management and outcomes of patients presenting with TAAD and acute lower extremity ischemia (ALI). The role of limb-related revascularization and optimal treatment strategy remains undefined. The objective of this study was to analyze dissection characteristics, treatment modalities, and outcomes of patients undergoing proximal aortic repair for TAAD with ALI.

Methods: Consecutive patients who underwent proximal aortic repair for TAAD were identified from a prospectively maintained database. Clinical data, imaging, operative details, and outcomes of patients with TAAD and ALI were retrospectively analyzed. Kaplan-Meier methodology was used to estimate overall and amputation-free survival. Log-rank tests were used to compare overall curves. Predictors of revascularization and in-hospital mortality were determined using multivariable logistic regression analysis.

Results: From 2010-2018, 463 patients with TAAD underwent proximal aortic repair. A total of 81 (17%) patients presented with ALI; 48% (39/81) with isolated ALI and 52% (42/81) with ALI and renovisceral malperfusion. Thirty percent (24/81) required revascularization in addition to proximal aortic repair. Revascularization strategies involved endovascular 46% (11/24), open 33% (8/24), and hybrid 21% (5/24) interventions. Major amputation rate was 4% (3/81) and in-hospital mortality was 21% (17/81). Amputation-free survival was significantly lower in patients requiring revascularization compared to those who did not (log-rank P=.023). Overall survival did not significantly differ between the two groups (log-rank P=.095). Overall survival was significantly lower in patients with concomitant ALI and renovisceral malperfusion compared to those with isolated ALI (log-rank P=.0017). Distal extent of dissection flap into zone 11 (OR 5.65, 95% CI [1.58-20.2]; p=.008) and partial/complete thrombosis of any iliac artery (OR 3.94, 95% CI [1.23-12.6]; p=.021) were associated with increased risk of requiring an additional revascularization procedure. True lumen collapse at level of renovisceral aorta (OR 8.84, 95% CI [1.74-44.9]; p=0.0086) was associated with increased risk of in-hospital mortality.

Conclusions: ALI resolves after proximal aortic repair of TAAD in most cases. Distal extent of aortic dissection into zone 11 and iliac thrombosis are risk factors for additional peripheral revascularization. True lumen collapse at the renovisceral aorta and TAAD with concomitant ALI and renovisceral malperfusion portends a poor prognosis. A multi-disciplinary team approach to manage these patients who present with ascending aortic dissection and distal malperfusion may improve outcomes in this complex population.
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http://dx.doi.org/10.1016/j.jvs.2021.08.050DOI Listing
September 2021

Coronary artery bypass grafting in low ejection fraction: state of the art.

Curr Opin Cardiol 2021 Sep 1. Epub 2021 Sep 1.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Purpose Of Review: As the number of patients with reduced ejection fraction secondary to ischemic cardiomyopathy (ICM) increases, coronary artery bypass grafting is being used with increasing frequency. In this review, we summarize the different operative considerations in this vulnerable patient population.

Recent Findings: Preoperative optimization with mechanical circulatory support devices, especially in the setting of hemodynamic instability, can reduce perioperative morbidity and mortality. The advantage of advanced techniques, such as off-pump CABG and multiple arterial grafting remains unclear. Concomitant procedures, such as ablation for atrial fibrillation remain important considerations that should be tailored to the individual patients risk profile.

Summary: Despite improvements in perioperative care of patients undergoing CABG, patients with a reduced ejection fraction remain at elevated risk of major morbidity and mortality. Preoperative optimization and careful selection of intraoperative techniques can lead to improved outcomes.
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http://dx.doi.org/10.1097/HCO.0000000000000908DOI Listing
September 2021

High take-off of the left coronary artery from the distal ascending aorta.

JTCVS Tech 2021 Aug 2;8:53-55. Epub 2021 Jun 2.

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

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http://dx.doi.org/10.1016/j.xjtc.2021.05.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8350948PMC
August 2021

Commentary: When possible, revascularize all the important coronary vessels at a minimum.

J Thorac Cardiovasc Surg 2021 Jul 6. Epub 2021 Jul 6.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.07.002DOI Listing
July 2021

Intraoperative graft patency validation: Friend or foe?

JTCVS Tech 2021 Jun 6;7:131-137. Epub 2021 Jan 6.

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

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http://dx.doi.org/10.1016/j.xjtc.2020.12.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311459PMC
June 2021

Commentary: Double trouble-Thoracoabdominal aortic aneurysm and heart failure.

JTCVS Tech 2021 Jun 4;7:51-52. Epub 2021 Mar 4.

Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.xjtc.2021.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311828PMC
June 2021

Surgical Repair for Primary Tricuspid Valve Disease: Individualized Surgical Planning With 3-Dimensional Printing.

JACC Case Rep 2020 Nov 18;2(14):2217-2222. Epub 2020 Nov 18.

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

Primary tricuspid valve (TV) disease is rare and associated with high operative mortality. Optimal surgical planning requires a precise understanding of the pathological features; however, detailed imaging of the TV can be challenging. We present 4 cases of primary TV disease where 3-dimensional printing was pivotal to operative planning and success. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.09.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299861PMC
November 2020

Commentary: Postcardiac surgery myocardial ischemia: Be on the lookout and sort it out!

J Thorac Cardiovasc Surg 2021 Jun 25. Epub 2021 Jun 25.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.06.036DOI Listing
June 2021

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

CABG: When, why, and how?

Cleve Clin J Med 2021 05 3;88(5):295-303. Epub 2021 May 3.

Director, Coronary Revascularization Center, Sheikh Hamdan bin Rashid Al Maktoum Distinguished Chair, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Coronary revascularization has matured as a field since coronary artery bypass grafting (CABG) was first developed over 50 years ago, with diagnostic and treatment methods having advanced dramatically. CABG remains the standard of care for obstructive coronary artery disease, particularly for patients with multivessel disease or diabetes. It is now recognized that not all CABG is created equal-operative strategy, including conduit choice for bypass grafts and target coronary selection, affects survival. A multidisciplinary approach including surgeons with a special interest in CABG is recommended to optimize treatment selection and outcomes.
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http://dx.doi.org/10.3949/ccjm.88a.20115DOI Listing
May 2021

Commentary: Timing of coronary artery bypass grafting after ST elevation myocardial infarction: All judgment, no magic.

J Thorac Cardiovasc Surg 2021 Mar 30. Epub 2021 Mar 30.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.083DOI Listing
March 2021

The 10 Commandments for Multiarterial Grafting.

Innovations (Phila) 2021 May-Jun;16(3):209-213. Epub 2021 Apr 18.

4435532569 Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.1177/15569845211003094DOI Listing
April 2021

The advantage of surgical revascularization in diabetic patients with multivessel disease: More arterial conduits, more benefit.

J Thorac Cardiovasc Surg 2021 Feb 27. Epub 2021 Feb 27.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.01.140DOI Listing
February 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

Intermediate-Term Outcomes of Endoscopic or Open Vein Harvesting for Coronary Artery Bypass Grafting: The REGROUP Randomized Clinical Trial.

JAMA Netw Open 2021 03 1;4(3):e211439. Epub 2021 Mar 1.

Perry Point Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.1439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961312PMC
March 2021

Commentary: How Expensive is the Cardiac Surgery Associated Acute Renal Dysfunction? It Comes Down to the Definition.

Semin Thorac Cardiovasc Surg 2021 Feb 16. Epub 2021 Feb 16.

Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2021.01.023DOI Listing
February 2021

Coronary artery aneurysms: outcomes following medical, percutaneous interventional and surgical management.

Open Heart 2021 02;8(1)

Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA

Background: Coronary artery aneurysms (CAAs) are increasingly diagnosed on coronary angiography; however, controversies persist regarding their optimal management. In the present study, we analysed the long-term outcomes of patients with CAAs following three different management strategies.

Methods: We performed a retrospective review of patient records with documented CAA diagnosis between 2000 and 2005. Patients were divided into three groups: medical management versus percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We analysed the rate of major cardiovascular and cerebrovascular events (MACCEs) over a period of 10 years.

Results: We identified 458 patients with CAAs (mean age 78±10.5 years, 74.5% men) who received medical therapy (N=230) or underwent PCI (N=52) or CABG (N=176). The incidence of CAAs was 0.7% of the total catheterisation reports. The left anterior descending was the most common coronary artery involved (38%). The median follow-up time was 62 months. The total number of MACCE during follow-up was 155 (33.8%); 91 (39.6%) in the medical management group vs 46 (26.1%) in the CABG group vs 18 (34.6%) in the PCI group (p=0.02). Kaplan-Meier survival analysis showed that CABG was associated with better MACCE-free survival (p log-rank=0.03) than medical management. These results were confirmed on univariate Cox regression, but not multivariate regression (OR 0.773 (0.526 to 1.136); p=0.19). Both Kaplan-Meier survival and regression analyses showed that dual antiplatelet therapy (DAPT) and anticoagulation were not associated with significant improvement in MACCE rates.

Conclusion: Our analysis showed similar long-term MACCE risks in patients with CAA undergoing medical, percutaneous and surgical management. Further, DAPT and anticoagulation were not associated with significant benefits in terms of MACCE rates. These results should be interpreted with caution considering the small size and potential for selection bias and should be confirmed in large, randomised trials.
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http://dx.doi.org/10.1136/openhrt-2020-001440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878141PMC
February 2021

Commentary: The coronary artery bypass grafting advantage: Fake assertion or obvious reality.

Authors:
Faisal G Bakaeen

J Thorac Cardiovasc Surg 2020 Oct 27. Epub 2020 Oct 27.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.070DOI Listing
October 2020

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

Serious Gastrointestinal Complications After Cardiac Surgery and Associated Mortality.

Ann Thorac Surg 2020 Nov 18. Epub 2020 Nov 18.

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

Background: Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality.

Methods: We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality.

Results: Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P < .001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P < .001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality.

Conclusions: Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.034DOI Listing
November 2020

Concomitant Surgical Ablation for Atrial Fibrillation: No Longer a Mitral Monopoly?

Ann Thorac Surg 2021 03 12;111(3):817-818. Epub 2020 Oct 12.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, J4-1, Cleveland, OH 44195. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2020.07.065DOI Listing
March 2021

Primary isolated CABG restrictive blood transfusion protocol reduces transfusions and length of stay.

J Card Surg 2020 Oct;35(10):2506-2511

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

Background: Cardiac surgery accounts for 10-15% of blood transfusions in the US, despite benefits and calls of limiting its use. We sought to evaluate the impact of a restrictive transfusion protocol on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG).

Methods: Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia, and pump fluid restriction with retrograde autologous priming and vacuum-assisted drainage, use of aminocaproic acid and cell saver, intra- and postoperative permissive anemia, and administration of iron and low-dose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009 to 2012 (group A; n = 375) and 2013 to 2016 (group B; n = 322) were compared.

Results: CABG with grafting to three or four coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 11% and 1.2%, and postoperative transfusion 20% and 5.6% (P < .0001 for all) in groups A and B, respectively. Median postoperative length of stay was 5.0 days in group A and 4.5 days in group B (P = .02), with no significant differences in mortality or morbidity.

Conclusions: A restrictive transfusion protocol reduced blood transfusions and postoperative length of stay without adversely affecting outcomes following isolated primary CABG.
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http://dx.doi.org/10.1111/jocs.14718DOI 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

Temporal improvements in perioperative stroke rates following coronary artery bypass grafting.

Curr Opin Cardiol 2020 11;35(6):679-686

Department of Thoracic and Cardiovascular Surgery, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Purpose Of Review: Perioperative stroke remains one of the most dreaded complications following coronary artery bypass grafting. In this review, we highlight the significant advances in understanding and preventing stroke in patients undergoing bypass surgery and offer our center's current best-practice recommendations to help avoid this debilitating outcome.

Recent Findings: The incidence of stroke has significantly reduced since the advent of coronary artery bypass graft surgery. Improvements in our understanding of the cause, mechanisms, risk factors, and diagnosis of stroke as well as refinements in medical optimization, surgical technique, and perioperative care all have contributed to making coronary artery bypass grafting safer even as patients have become increasingly complex.

Summary: The field of cardiothoracic surgery endures in its quest to eliminate the risk of perioperative stroke. By incorporating the lessons of the past into our innovations of the future, cardiac surgeons will continue to strive for safer coronary artery bypass grafting and afford patients to not only live longer but better as well.
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http://dx.doi.org/10.1097/HCO.0000000000000798DOI Listing
November 2020

Performance and Durability of Cryopreserved Allograft Aortic Valve Replacements.

Ann Thorac Surg 2021 06 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

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

Discussion.

Authors:
Faisal G Bakaeen

J Thorac Cardiovasc Surg 2020 Jul 16. Epub 2020 Jul 16.

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http://dx.doi.org/10.1016/j.jtcvs.2020.03.167DOI Listing
July 2020

PCI or CABG for Left Main Coronary Artery Disease.

N Engl J Med 2020 07;383(3):292

Cleveland Clinic, Cleveland, OH

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http://dx.doi.org/10.1056/NEJMc2000645DOI Listing
July 2020

Coronary Revascularization Strategies: Making Sense of Sparse, Limited-Quality Data.

JAMA 2020 07;324(2):154-156

Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jama.2020.8548DOI Listing
July 2020
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