Publications by authors named "Mario F L Gaudino"

45 Publications

Transit time flow measurement in coronary artery bypass grafting: For every patient and every surgeon.

J Card Surg 2021 Sep 14. Epub 2021 Sep 14.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA.

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http://dx.doi.org/10.1111/jocs.15994DOI Listing
September 2021

Commentary: Transit time flow measurements for coronary artery bypass graft: Go with the flow.

JTCVS Tech 2021 Jun 26;7:144-145. Epub 2020 Dec 26.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY.

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http://dx.doi.org/10.1016/j.xjtc.2020.12.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311445PMC
June 2021

The STS CABG composite measure: 2021 methodology update.

Ann Thorac Surg 2021 Jul 16. Epub 2021 Jul 16.

Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.

Background: The original STS CABG composite measure uses a 1-year analytic cohort and 98% credible intervals (CrI) to classify better (3-star) or worse (1-star) than expected performance. As CABG volumes per STS participant (e.g., hospital or practice group) have decreased, it has become more challenging to classify performance categories using this approach, especially for lower volume programs, and alternative approaches have been explored.

Methods: Among 990 STS Adult Cardiac Surgery Database participants, performance classifications for the CABG composite were studied using various analytic cohorts: single year (current approach, 2017); 3 years (2015-2017); last 450 cases within 3 years; most recent year (2017) plus additional cases to 450 total. We also compared 98% CrI with 95% CrI (used in other STS composite measures).

Results: Using 3 years of data and 95% CrI's, 113 of 990 participants (11.4%) were classified 1-star and 198 (20%) 3-star. Compared with 1-year analytic cohorts and 98% CrI, the absolute and relative increases in the proportion of 3-star participants were 14 percentage points and 233% (n=198[20%] versus n=59[6%]). Corresponding changes for 1-star participants were 6.5 percentage points and 133% (n=113[11.4%] versus n=48[4.9%]). These changes were particularly notable among lower volume (<199 CABG/year) participants. Measure reliability with the 3-year, 95% CrI modification is 0.78.

Conclusions: Compared with current STS CABG composite methodology, a 3-year analytic cohort and 95% CrI increases the number and proportion of better or worse than expected outliers, especially among lower-volume ACSD participants. This revised methodology is also now consistent with other STS procedure composites.
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http://dx.doi.org/10.1016/j.athoracsur.2021.06.036DOI Listing
July 2021

Commentary: Methods in observational studies in valve surgery, when time matters.

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

Department of Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, United Kingdom; University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, United Kingdom.

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.082DOI Listing
March 2021

Splanchnic occlusive disease predicts for spinal cord injury after open descending thoracic and thoracoabdominal aneurysm repair.

J Vasc Surg 2021 Mar 5. Epub 2021 Mar 5.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.

Objective: In the present study, we sought to discern the effects of splanchnic occlusive disease (SOD; renal, superior mesenteric, and/or celiac axis arteries) on spinal cord injury (SCI; paraparesis or paraplegia) and major adverse events (MAE) after descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair.

Methods: Patients who had undergone DTA/TAAA repair at our institution were dichotomized according to the presence of SOD, which was investigated as a predictive factor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, tracheostomy, de novo dialysis, MAE, survival) endpoints. Risk adjustment used both propensity score matching and multivariable logistic regression.

Results: From July 1997 to October 2019, 888 patients had undergone DTA/TAAA repair, of whom 19 were excluded from our analysis for missing data. SOD was absent in 712 patients and present in 157 patients. The patients with SOD had presented with a greater incidence of preoperative renal impairment (61 [38.9%] vs 175 [24.6%]; P < .01) and peripheral arterial disease (60 [38.2%] vs 162 [22.8%]; P < .01] and decreased left ventricular ejection fraction (45%; interquartile range, 10%; vs 50%; interquartile range, 4%; P < .01). The etiology of aortic disease was more frequently dissection in the SOD group (56.1% vs 43.7%) and more frequently nondissecting aneurysm in the non-SOD group (56.3% vs 43.9%; P < .01). Patients without SOD had presented with aneurysms more cranially located (DTA, 34.0% vs 7.6%; extent I TAAA, 44.0% vs 7.6%). In contrast, patients with SOD had presented with aneurysms more caudally located (extent II TAAA, 36.9% vs 8.6%; extent III TAAA, 30.6% vs 11.0%; extent IV TAAA, 17.2% vs 2.5%; P < .01). Propensity score matching led to 144 pairs, with SOD significantly associated with SCI (10 [6.9%] vs 2 [1.4%]; P = .03) and MAE (47 [32.6%] vs 26 [15%]; P < .01). Ten-year survival was reduced in those with SOD (31.5% vs 45.2%; P < .01). Conditional multivariable regression confirmed SOD to be a predictor of SCI in the matched sample (odds ratio, 6.60; P = .02).

Conclusions: Our results have shown that SOD is a significant predictor of SCI in patients undergoing open DTA/TAAA repair. The investigation of measures to prolong neuronal ischemia tolerance (eg, hypothermia) is warranted for such patients.
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http://dx.doi.org/10.1016/j.jvs.2021.02.030DOI Listing
March 2021

Toward stroke-free coronary surgery: The role of the anaortic off-pump bypass technique.

J Card Surg 2021 Apr 27;36(4):1499-1510. Epub 2021 Jan 27.

Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.

Surgical coronary revascularization remains the preferred strategy in a significant portion of patients with coronary artery disease due to superior long-term outcomes. However, there is a significant risk of perioperative neurologic injury that has influenced guideline recommendations. These complications occur in 1%-5% of patients, ranging from overt neurologic deficits with permanent disability, to subtle cerebral defects noted on neuroimaging that may result in slow cognitive and functional decline. The primary mechanism by which these events occur is thromboembolism from manipulation of the ascending aorta. This occurs during cardiopulmonary bypass, aortic cross-clamping, and partial occlusion clamping (side clamp). Elderly patients and patients with aortic atheroma are, therefore, at significantly increased risk. Initial surgical techniques addressed this by aggressively debriding or replacing the ascending aorta during coronary artery bypass grafting (CABG). Strategies then moved toward minimizing aortic manipulation through pump-assisted beating heart surgery and off-pump surgery with partial occlusion clamping or proximal anastomosis devices. Finally, anaortic off-pump CABG aims to avoid all manipulation of the ascending aorta through advanced off-pump grafting techniques combined with in situ and composite grafts. This has been demonstrated to result in the greatest reduction in risk. Establishing successful anaortic off-pump CABG programs requires subspecialization and focused interest groups dedicated to advancing CABG outcomes.
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http://dx.doi.org/10.1111/jocs.15372DOI Listing
April 2021

How to build a multi-arterial coronary artery bypass programme: a stepwise approach.

Eur J Cardiothorac Surg 2020 12;58(6):1111-1117

Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.

Observational evidence shows that the use of multiple arterial grafts (MAG) is associated with longer postoperative survival and improved clinical outcomes. The current European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization recommend the use of MAG in appropriate patients. However, a significant volume-to-outcome relationship exists for MAG, and lack of sufficient experience is associated with increased operative risk. A stepwise approach to building experience with MAG allows successful implementation of this technique into routine coronary surgery practice.
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http://dx.doi.org/10.1093/ejcts/ezaa377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824806PMC
December 2020

Outcomes following revascularization with radial artery bypass grafts: Insights from the PREVENT-IV trial.

Am Heart J 2020 10 8;228:91-97. Epub 2020 Aug 8.

Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.

Background: The optimal role of radial artery grafts in coronary artery bypass grafting (CABG) remains uncertain. The purpose of this study was to examine angiographic and clinical outcomes following CABG among patients who received a radial artery graft.

Methods: Patients in the angiographic cohort of the PREVENT-IV trial were stratified based upon having received a radial artery graft or not during CABG. Baseline characteristics and 1-year angiographic and 5-year clinical outcomes were compared between patients.

Results: Of 1,923 patients in the angiographic cohort of PREVENT-IV, 117 received a radial artery graft. These patients had longer surgical procedures (median 253 vs 228 minutes, P < .001) and had a greater number of grafts placed (P < .0001). Radial artery grafts had a graft-level failure rate of 23.0%, which was similar to vein grafts (25.2%) and higher than left internal mammary artery grafts (8.3%). The hazard of the composite clinical outcome of death, myocardial infarction, or repeat revascularization was similar for both cohorts (adjusted hazard ratio 0.896, 95% CI 0.609-1.319, P = .58). Radial graft failure rates were higher when used to bypass moderately stenotic lesions (<75% stenosis, 37% failure) compared with severely stenotic lesions (≥75% stenosis, 15% failure).

Conclusions: Radial artery grafts had early failure rates comparable to saphenous vein and higher than left internal mammary artery grafts. Use of a radial graft was not associated with a different rate of death, myocardial infarction, or postoperative revascularization. Despite the significant potential for residual confounding associated with post hoc observational analyses of clinical trial data, these findings suggest that when clinical circumstances permit, the radial artery is an acceptable alternative to saphenous vein and should be used to bypass severely stenotic target vessels.
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http://dx.doi.org/10.1016/j.ahj.2020.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508822PMC
October 2020

Commentary: Time will tell.

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

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.06.096DOI Listing
July 2020

Reply: A question versus the question.

J Thorac Cardiovasc Surg 2020 Jul 23. Epub 2020 Jul 23.

Department of Cardiothoracic Surgery, Weill-Cornell Medical College, New York, NY.

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http://dx.doi.org/10.1016/j.jtcvs.2020.06.027DOI Listing
July 2020

Two- or 3-Dimensional Echocardiography-Derived Cardiac Output Cannot Replace the Pulmonary Artery Catheter in Cardiac Surgery.

J Cardiothorac Vasc Anesth 2020 Oct 24;34(10):2691-2697. Epub 2020 Jun 24.

Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Medical Center, New York, NY.

Objectives: Three-dimensional (3D) transesophageal echocardiography (TEE) has been shown to be more accurate than 2D TEE for the evaluation of the left ventricular outflow tract area. The aim of the present study was to compare the agreement of 3D echocardiography-derived cardiac output (CO) with thermodilution-derived CO (TDCO) before and after cardiopulmonary bypass (CPB).

Design: This was a prospective observational study of patients who underwent cardiac surgery between 2016 and 2018.

Setting: Weill Cornell Medicine, a single large academic medical center.

Participants: The study comprised 78 patients undergoing elective cardiac surgery.

Interventions: CPB, TEE, pulmonary artery catheter, and elective cardiac surgery.

Measurements And Main Results: Two-dimensional CO, 3D CO-diameter, and 3D CO-area values pre-CPB were strongly correlated with one another both pre-CPB and post-CPB. The 3D CO-diameter and the 3D CO-area were mildly correlated, with TDCO measurements pre-CPB (r = 0.46 and 0.39, respectively) and post-CBP (r = 0.43 and 0.47, respectively). Pre-CPB 3D CO-diameter had the most agreement with TDCO in terms of bias (-0.13 L/min); however, the limits of agreement (LOA) were wide (-2.2- to- 2.45 L/min). Post-CPB, 3D CO-diameter had the most agreement with TDCO in terms of bias (0.41) but with wide LOA (-3.29 to 2.47). All pre-CPB echocardiography-derived CO (2D CO, 3D CO-diameter, 3D CO-area) had more agreement with TDCO than did post-CPB measurements.

Conclusions: Three-dimensional CO measurements were only modestly correlated with pulmonary artery catheter-derived CO pre-bypass and post-bypass. Despite low bias, the wide LOA from 2D CO, 3D CO-diameter, and 3D-area compared with TDCO suggested that the 2 methods are not interchangeable.
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http://dx.doi.org/10.1053/j.jvca.2020.06.068DOI Listing
October 2020

The Need for Randomized Trials in Cardiac Surgery.

Ann Thorac Surg 2021 02 30;111(2):636. Epub 2020 Jun 30.

Department of Cardiothoracic Surgery, Weill Cornell Medicine | New York-Presbyterian Hospital, 525 E 68th St, New York, NY 10021. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2020.05.063DOI Listing
February 2021

Effect of Skeletonization of Bilateral Internal Thoracic Arteries on Deep Sternal Wound Infections.

Ann Thorac Surg 2021 02 26;111(2):600-606. Epub 2020 Jun 26.

Society of Thoracic Surgeons Research Center, Chicago, Illinois.

Background: Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

Methods: Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching.

Results: We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories.

Conclusions: The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890569PMC
February 2021

Differential myocardial strain in the early postoperative period in patients receiving arterial vs venous bypass grafts: A hypothesis-generating study.

J Card Surg 2020 Aug 24;35(8):1824-1831. Epub 2020 Jun 24.

Department of Cardiothoracic Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York.

Objective: Revascularization via coronary artery bypass grafting (CABG) remains a common therapy for coronary artery disease. CABG-based revascularization is most commonly performed via either single arterial graft (SAG) or multiple arterial grafting (MAG) strategies. Echo-derived global and regional longitudinal strain was used to test where SAG or MAG results in immediate differences in left ventricular (LV) function after CABG.

Materials And Methods: Pre- and postprocedural intraoperative transesophageal echos were prospectively collected. Two-dimensional LV images were analyzed for global and regional longitudinal strain (GLS), LV ejection fraction, end-diastolic volume, end-systolic volume, and stroke volume (SV).

Results: Twenty patients underwent open, on-pump CABG (63.9 ± 10 years old, 85% male; 10 with SAG and 10 with MAG. Preprocedural GLS significantly differed between patients with SAG and MAG, with patients with MAG having greater GLS (mean [standard deviation, SD], 20.41 [5.54]) than patients with SAG (16.28 [3.48]). After CABG, in patients with MAG, LV strain decreased both globally (-1.13 [3.15]) and regionally in the anterior-lateral (-1.22 [3.84]) and inferior-lateral regions (-1.32 [5.69]), along with LVEF. In patients with SAG, LV strain increased after CABG globally (1.34 [2.73]) and regionally in the anterior-lateral (1.20 [6.49]) and inferior-lateral regions (0.39 [7.26]), as did LVEF and SV. Postprocedure, more patients with MAG were given vasopressor (100% vs 60%) and inotrope infusions (70% vs 40%) than patients with SAG.

Conclusions: After CABG, LV function quantified through GLS changes both globally and regionally increased after SAG and decreased after MAG. This finding may have important clinical implications in terms of optimizing intraoperative management for patients with CABG and have the potential to guide the improvement of clinical outcomes.
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http://dx.doi.org/10.1111/jocs.14695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882211PMC
August 2020

Commentary: To BIMA or not to BIMA, that should be the question, rather than how to BIMA.

J Thorac Cardiovasc Surg 2020 Apr 5. Epub 2020 Apr 5.

Department of Cardiothoracic Surgery, Weill-Cornell Medical College, New York, NY.

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http://dx.doi.org/10.1016/j.jtcvs.2020.03.063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869016PMC
April 2020

Commentary: If the news is good, it is better that we know … if the news is bad, it is better than we know fast.

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

Department of Cardiothoracic Surgery, Weill Cornell Medicine/New York Presbyterian, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.02.058DOI Listing
February 2020

Prosthetic aortic graft replacement of the ascending thoracic aorta alters biomechanics of the native descending aorta as assessed by transthoracic echocardiography.

PLoS One 2020 12;15(3):e0230208. Epub 2020 Mar 12.

Department of Medicine (Cardiology), Weill Cornell Medicine, New York, New York, United States of America.

Introduction: In patients with ascending aortic (AA) aneurysms, prosthetic graft replacement yields benefit but risk for complications in the descending aorta persists. Longitudinal impact of AA grafts on native descending aortic physiology is poorly understood.

Methods: Transthoracic echocardiograms (echo) in patients undergoing AA elective surgical grafting were analyzed: Descending aortic deformation indices included global circumferential strain (GCS), time to peak (TTP) strain, and fractional area change (FAC). Computed tomography (CT) was used to assess aortic wall thickness and calcification.

Results: 46 patients undergoing AA grafting were studied; 65% had congenital or genetically-associated AA (30% bicuspid valve, 22% Marfan, 13% other): After grafting (6.4±7.5 months), native descending aortic distension increased, irrespective of whether assessed based on circumferential strain or area-based methods (both p<0.001). Increased distensibility paralleled altered kinetics, as evidenced by decreased time to peak strain (p = 0.01) and increased velocity (p = 0.002). Augmented distensibility and flow velocity occurred despite similar pre- and post-graft blood pressure and medications (all p = NS), and was independent of pre-surgical aortic regurgitation or change in left ventricular stroke volume (both p = NS). Magnitude of change in GCS and FAC was 5-10 fold greater among patients with congenital or genetically associated AA vs. degenerative AA (p<0.001), paralleling larger descending aortic size, greater wall thickness, and higher prevalence of calcific atherosclerotic plaque in the degenerative group (all p<0.05). In multivariate analysis, congenital/genetically associated AA etiology conferred a 4-fold increment in magnitude of augmented native descending aortic strain after proximal grafting (B = 4.19 [CI 1.6, 6.8]; p = 0.002) independent of age and descending aortic size.

Conclusions: Prosthetic graft replacement of the ascending aorta increases magnitude and rapidity of distal aortic distension. Graft effects are greatest with congenital or genetically associated AA, providing a potential mechanism for increased energy transmission to the native descending aorta and adverse post-surgical aortic remodeling.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230208PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7067394PMC
June 2020

Commentary: "Get moving early!" Inpatient cardiac rehabilitation reduces unplanned hospitalizations.

J Thorac Cardiovasc Surg 2021 05 26;161(5):1861-1862. Epub 2019 Dec 26.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.12.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316606PMC
May 2021

Impact of left ventricular ejection fraction on the outcomes of open repair of descending thoracic and thoracoabdominal aneurysms.

J Thorac Cardiovasc Surg 2021 02 22;161(2):534-541.e5. Epub 2019 Nov 22.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.

Objective: To discern the impact of depressed left ventricular ejection fraction (LVEF) on the outcomes of open descending thoracic aneurysm (DTA) and thoracoabdominal aneurysms (TAAA) repair.

Methods: Restricted cubic spline analysis was used to identify a threshold of LVEF, which corresponded to an increase in operative mortality and major adverse events (MAE: operative death, myocardial infarction, stroke, spinal cord injury, need for tracheostomy or dialysis). Logistic and Cox regression were performed to identify independent predictors of MAE, operative mortality, and survival.

Results: DTA/TAAA repair was performed in 833 patients between 1997 and 2018. Restricted cubic spline analysis showed that patients with LVEF <40% (n = 66) had an increased risk of MAE (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.22-3.87; P < .01) and operative mortality (OR, 2.72; 95% CI, 1.21-6.12; P = .02) compared with the group with LVEF ≥40% (n = 767). The group with LVEF <40% had a worse preoperative profile (eg, coronary revascularization, 48.5% vs 17.3% [P < .01]; valvular disease, 82.8% vs 49.39% [P < .01]; renal insufficiency, 45.5% vs 26.1% [P < .01]; respiratory insufficiency, 36.4% vs 21.2% [P = .01]) and worse long-term survival (35.5% vs 44.7% at 10 years; P = .01). Nonetheless, on multivariate regression, depressed LVEF was not an independent predictor of operative mortality, MAE, or survival.

Conclusions: LVEF is not an independent predictor of adverse events in surgery for DTA.
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http://dx.doi.org/10.1016/j.jtcvs.2019.11.009DOI Listing
February 2021

Valve-sparing root replacement in patients with bicuspid aortopathy: An analysis of cusp repair strategy and valve durability.

J Thorac Cardiovasc Surg 2021 02 24;161(2):469-478. Epub 2019 Oct 24.

Weill Cornell Medicine Department of Cardiothoracic Surgery, New York, NY.

Objective: Valve-sparing root replacement using reimplantation techniques is increasingly applied to bicuspid aortopathy. Long-term durability of cusp repair is unclear. We analyze midterm results using a conservative approach to cusp repair.

Methods: From 2006 to 2018, 327 patients underwent valve-sparing reimplantation, 66 with bicuspid valves. Leaflets were analyzed after reimplantation. A majority (51/66) required no cusp repair. Fifteen patients had cusp repair limited to closure of unfused raphe or central plication. Patients were followed by echocardiography.

Results: Mean age of patients was 44.7 ± 12.3 years. The cusp repair group had a higher incidence of preoperative moderate (10% vs 40%) or severe (4% vs 33.3%) aortic insufficiency (P < .001). There was no operative mortality or major complication. Mean follow-up was 51.6 ± 40.8 months. On postoperative echocardiography, incidence of none, trace, or mild aortic insufficiency was 41.3% (19/46), 43.5% (20/46), and 15.2% (7/46) in the no cusp repair group and 40% (6/15), 40% (6/15), and 20% (3/15) in the cusp repair group, respectively (P = .907). Few patients progressed in degree of aortic insufficiency. No patients required reoperation. At 5 years, freedom from any aortic insufficiency was 46.9% versus 15.8% (P = .013), and freedom from greater than trace aortic insufficiency was 59.1% versus 36.9% (P = .002) due to the higher rate of postoperative trace and mild aortic insufficiency with cusp repair. There was no difference in freedom from greater than mild aortic insufficiency (92.1% vs 100%; P = .33).

Conclusions: Valve-sparing root replacement is reliably performed with bicuspid aortic valves whether or not cusp reconstruction is necessary. Few patients progress to greater than mild aortic insufficiency. Need for reoperation is rare in midterm follow-up.
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http://dx.doi.org/10.1016/j.jtcvs.2019.10.048DOI Listing
February 2021

Commentary: Inching way on the impervious path from art to science.

J Thorac Cardiovasc Surg 2020 03 17;159(3):e189-e190. Epub 2019 Sep 17.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.08.048DOI Listing
March 2020

Single- versus multidose cardioplegia in adult cardiac surgery patients: A meta-analysis.

J Thorac Cardiovasc Surg 2020 Nov 5;160(5):1195-1202.e12. Epub 2019 Sep 5.

Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Medical Center, New York, NY.

Objective: To compare outcomes of single (intervention group: del Nido [DN], and histamine-tryptophan-ketoglutarate) versus multidose (control group) cardioplegia in the adult cardiac surgery patients.

Methods: Medical search engines were interrogated to identify relevant randomized controlled trials and propensity-score matched cohorts. Meta-analysis was conducted for primary (in-hospital/30-day mortality) and secondary (ischemic and cardiopulmonary bypass [CPB] times, reperfusion fibrillation, peak of cardiac enzymes, myocardial infarction) endpoints. Subgroup analyses were conducted for study design and type of intervention, and meta-regression for primary outcome included type of surgery and left ventricular ejection fraction as moderators.

Results: Ten randomized controlled trials and 13 propensity-score matched cohorts were included, reporting on 5516 patients. Estimates are expressed as (parameter value [OR, odds ratio; MD, mean difference; SMD, standardized mean difference]/unit of measure [95% confidence interval], P value). DN reduced ischemic time (MD, -7.18 minutes [-12.52 to -1.84], P < .01), CPB time (MD, -10.44 minutes [-18.99 to -1.88], P .01), reperfusion fibrillation (OR, 0.16 [0.05-0.54], P < .01), and cardiac enzymes (SMD -0.17 [-0.29, 0.05], P < .01) compared with multidose cardioplegia. None of these beneficial effects were reproduced by histamine-tryptophan-ketoglutarate, which instead increased CPB time (MD, 2.04 minutes [0.73-3.37], P < .01) and reperfusion fibrillation (OR, 1.80 [1.20-2.70], P < .01). There was no difference in mortality and myocardial infarction between single and multidose, independently of type of surgery or left ventricular ejection fraction.

Conclusions: DN decreases operative times, reperfusion fibrillation, and surge of cardiac enzymes compared with multidose cardioplegia.
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http://dx.doi.org/10.1016/j.jtcvs.2019.07.109DOI Listing
November 2020

Immediate Impact of Prosthetic Graft Replacement of the Ascending Aorta on Circumferential Strain in the Descending Aorta.

Eur J Vasc Endovasc Surg 2019 Oct 21;58(4):521-528. Epub 2019 Aug 21.

Department of Cardiology/Medicine, Weill Cornell Medicine, New York Presbyterian, NY, NY, USA.

Objectives: Prosthetic replacement of the ascending aorta (AA) can potentially modify energy propagation to the distal aorta and contribute to adverse aortic remodelling. This preliminary study employed intra-operative transoesophageal echocardiography (TOE) to assess the immediate impact of prosthetic graft replacement of the AA on circumferential strain in the descending aorta.

Methods: Intra-operative TOEs in patients undergoing AA graft replacement were analysed for circumferential strain, fractional area change (FAC), dimensions (end diastolic area [EDA], and end systolic area [ESA]) in the descending aorta immediately before and after graft replacement. Deformation was assessed via global peak circumferential aortic strain (CAS), together with pulse pressure corrected strain, time to peak strain (TTP), and aortic distensibility.

Results: Forty-five patients undergoing AA replacement with prosthetic graft (91% elective) were studied. Following grafting, descending thoracic aortic circumferential strain increased (6.3 ± 2.8% vs. 8.9 ± 3.4%, p = .001) paralleling distensibility (5.7 [3.7-8.6] 10 mmHg vs. 8.5 [6.4-12.4] 10 mmHg, p < .001). Despite slight increments in post graft left ventricular ejection fraction (LVEF) (52.3 ± 10.8% vs. 55.0 ± 11.9, p < .001), stroke volume was similar (p = .41), and magnitude of increased strain did not correlate with change in stroke volume (r = -.03, p = .86), LVEF (r = .18, p = .28), or pulse pressure (r = .28, p = .06). Descending aortic size (EDA 4 [2.7-4.6] cmvs. 3.7 [2.5-5] cm, p = .89; ESA 4.3 [3.2-5.3] cmvs. 4.5 [3.3-5.8] cm, p = .14) was similar pre- and post graft. In subgroup analysis, patients with cystic medial necrosis had a significantly higher post procedure CAS than patients with atherosclerotic aneurysms (9.7 ± 3.5% vs. 7.0 ± 2.3%, p = .03).

Conclusions: Prosthetic graft replacement of the AA increases immediate aortic circumferential strain of the descending aorta, particularly in patients with cystic medial necrosis. Our findings suggest that grafts augment energy transfer to the distal aorta, a potential mechanism for progressive distal aortic dilation and/or dissection.
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http://dx.doi.org/10.1016/j.ejvs.2019.05.003DOI Listing
October 2019

Commentary: Saphenous vein graft risk score: But where is the vein?

J Thorac Cardiovasc Surg 2020 07 25;160(1):128-129. Epub 2019 Jul 25.

Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.07.031DOI Listing
July 2020

Preventing treatment failures in coronary artery disease: what can we learn from the biology of in-stent restenosis, vein graft failure, and internal thoracic arteries?

Cardiovasc Res 2020 03;116(3):505-519

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.

Coronary artery disease (CAD) remains one of the most important causes of morbidity and mortality worldwide, and the availability of percutaneous or surgical revascularization procedures significantly improves survival. However, both strategies are daunted by complications which limit long-term effectiveness. In-stent restenosis (ISR) is a major drawback for intracoronary stenting, while graft failure is the limiting factor for coronary artery bypass graft surgery (CABG), especially using veins. Conversely, internal thoracic artery (ITA) is known to maintain long-term patency in CABG. Understanding the biology and pathophysiology of ISR and vein graft failure (VGF) and mechanisms behind ITA resistance to failure is crucial to combat these complications in CAD treatment. This review intends to provide an overview of the biological mechanisms underlying stent and VGF and of the potential therapeutic strategy to prevent these complications. Interestingly, despite being different modalities of revascularization, mechanisms of failure of stent and saphenous vein grafts are very similar from the biological standpoint.
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http://dx.doi.org/10.1093/cvr/cvz214DOI Listing
March 2020

Multiarterial coronary artery bypass grafting: is the radial artery fulfilling the unkept promise of the right internal thoracic artery?

Curr Opin Cardiol 2019 11;34(6):628-636

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA.

Purpose Of Review: The debate on the second best conduit for CABG is still intense. In this review, we discuss the role of the radial artery and the right internal thoracic artery (RITA) compared with saphenous vein grafts (SVG).

Recent Findings: The recent RADIAL STUDY has been the first evidence based on randomized trials of a clinical benefit using a second arterial graft in CABG.On the other hand, the definitive 10-year results of the ART trial failed to show a clinical advantage associated with the use of bilateral internal thoracic artery (BITA). A thorough and contextualized analysis of this and other studies, however, may offer a different perspective.

Summary: Arterial conduits in CABG have shown better patency rates than SVG. Whether this leads to better clinical outcomes is still debated. In this setting, the radial artery and the RITA seem to offer a similar advantage, although with different indications and contraindications.
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http://dx.doi.org/10.1097/HCO.0000000000000670DOI Listing
November 2019

Right internal thoracic or radial artery as the second arterial conduit for coronary artery bypass surgery.

Curr Opin Cardiol 2019 09;34(5):564-570

Department of Cardiothoracic Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York, USA.

Purpose Of Review: To summarize the available evidence on the use of the right internal thoracic artery (RITA) and the radial artery as the second arterial graft in coronary artery bypass surgery.

Recent Findings: The current data support the equipoise of the two conduits in terms of clinical and angiographic outcomes. Both RITA and radial artery have better patency than saphenous vein grafts. The use of the RITA carries an increased risk of deep sternal wound infection (DSWI) if the artery is harvested as pedicle. Bilateral internal thoracic artery grafting is more technically demanding than radial artery use and there is a volume-outcome relationship in terms of mortality and incidence of DSWI. The radial artery is preferable over RITA in right-sided or distal circumflex artery targets with high-degree stenosis and in patients at higher risk for DSWI, whereas it is not recommended to graft vessels with moderate stenosis and in cases of insufficient collateralization from the ulnar artery or previous transradial procedures.

Summary: The patency rate and clinical outcomes of radial artery and RITA are similar. The use of one or the other should be based on a careful evaluation of the patient's coronary anatomy and comorbidities, the conduit availability and the surgeon's and center's experience.
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http://dx.doi.org/10.1097/HCO.0000000000000654DOI Listing
September 2019

Characteristics and anatomic distribution of early vs late stroke after cardiac surgery.

J Card Surg 2019 Aug 18;34(8):684-689. Epub 2019 Jun 18.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.

Background: The primary objective of this study was to identify the specific predictors of early and late stroke in patients after open heart surgery. Secondary outcomes included (a) risk factors for perioperative stroke, (b) anatomic location of stroke according to time of presentation, and (c) the impact of stroke on operative mortality.

Methods: Adult patients undergoing open cardiac surgery with cardiopulmonary bypass from 2006 to 2016 at the New York Presbyterian Hospital/Weill Cornell Medicine were retrospectively reviewed. In total 7957 patients were included. We compared the demographic and perioperative variables in three groups: no stroke, early stroke, and late stroke using regression analysis.

Results: The incidence of perioperative stroke for the entire study period was 1.5% (117 of 7957). Early stroke occurred in 84 (71.8%) patients, whereas late stroke occurred in 33 (28.2%). Early strokes were usually embolic events (64 of 66, 97.0%, P = .66) on the right side (30 of 66, 45.5%, P < .001), in the anterior circulation (38 of 66, 57.6%, P = .001), or in multiple distributions (28 of 66, 42.4%, P = .002). Late strokes were more likely left-sided (16 of 28, 57.1%, P < .001) and uncommonly in both the anterior and posterior hemispheres (1 of 28, 3.6%, P = .001). Stroke, regardless of timing, was a significant predictor of operative mortality (odds ratio, 11.0, confidence interval, 6.1-19.7, P < .001).

Conclusions: Early and late strokes after cardiac surgery have distinct incidence, location, and likely etiology. Both early and late strokes portend a very high incidence of operative mortality.
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http://dx.doi.org/10.1111/jocs.14121DOI Listing
August 2019

Surgery for chronic type B dissection with aneurysmal degeneration.

Indian J Thorac Cardiovasc Surg 2019 Jun 15;35(Suppl 2):169-173. Epub 2018 Aug 15.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th St., M-404, New York, NY 10065 USA.

Purpose: Open repair of descending thoracic or thoracoabdominal aortic aneurysm (TAAA) continues to carry a not insignificant operative risk, even in experienced hands. Over the past three decades, there has been considerable improvement in both the mortality and morbidity associated with these procedures. Herein, we describe our operative results and long-term outcomes in patients with chronic type B aortic dissections.

Methods: Review of the aortic surgical database was conducted to identify all consecutive patients who underwent repair of TAAA for chronic type B dissection from May 1997 to March 2018. The primary end point was operative mortality with secondary end points as the composite of major adverse events as well as each of the individual complications.

Results: One hundred and fifty-three patients met inclusion criteria with 54.9% (84/153) having surgery on an elective basis. The mean age was 58.9 years with a majority of male gender-107/153 (69.9%). Eighty-three (54.2%) of the TAAA were extent I, while 36 (23.5%) were extent II and 34 (22.3%) extent III-IV. Operative mortality was 8.5% (13/153) with eight of the deaths in patients who presented with extent II TAAA. On Kaplan-Meier survival analysis, 87.5% (95% confidence interval (CI) 77.9-97.1%) of the elective cohort were alive after 5 years while only 69.9% (CI 55.2-84.6%) of those in need of urgent/emergency intervention survived ( = .039).

Conclusions: In a majority of patients with chronic type B dissections, reproducibly, excellent outcomes can be achieved with relatively low risk of mortality. In the higher risk subsets of patients with extent II TAAA, careful consideration and discussion of expected outcomes will help inform the decision-making process.
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http://dx.doi.org/10.1007/s12055-018-0691-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525403PMC
June 2019
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