Journal and News Scan

The Stanford University cardiac surgery team expounds on current evidence for selection of prostheses in valve replacement. While more liberal usage of biologic prostheses in younger patients may be appropriate for the aortic valve, the support for this practice in the mitral position is not as strong. The enthusiasm for biologic valve implantation in the mitral position for young patients should be tempered. As transcatheter technologies continue to develop, the risk-benefit trade-off between biologic and mechanical valves will evolve. However, until procedural safety and long term durability is proven, reliance on these technologies as a routine salvage procedure may be overly optimistic.

Currently no frozen elephant trunk (FET) prosthesis are readily available in the United States. This University of Colorado team developed a surgical technique to simplify the FET procedure, termed the Buffalo Trunk, which obviates the need for a hybrid graft and decreases operating times.

This technique utilizes a soft-branched graft along with a stent graft to create a distal anastomosis that incorporates the aorta, stent graft, and soft graft in a zone 2 arch reconstruction. The preliminary results in 37 patients undergoing the Buffalo Trunk versus 28 undergoing FET showed that the Buffalo technique has facilitated shorter circulatory arrest time, and subsequently overall decreased operative times without compromising outcomes.

The culture of health care creates important challenges for health care professionals. In particular, this culture is 1) hierarchical, 2) competitive, and 3) perfectionistic. Unfortunately, the tendency of acquiescing to those demands is contrary to promoting resonant teamwork. It is important for leaders of multidisciplinary teams to understand how to create environments that flatten the hierarchy (by encouraging all team members to contribute and to genuinely seek the wisdom and knowledge of their colleagues), that encourage collaboration and cooperation (emphasizing collective “wins” and “losses” both for the immediate team as well as for all of us, as a profession), and that invites excellence (which is a process) rather than an expectation of perfection (which is an unrealistic outcome).

In this article, the authors outline the concepts that promote development of this kind of leadership thinking, which covers topics like emotional intelligence, professionalism, interpersonal and communication skills, and efficient, timely, equitable, unprejudiced and patient-centered care.

This a must-read for cardiothoracic surgeons, who are always leading their surgical team.

Although both bicuspid aortic valve (BAV) and Marfan syndrome have been associated with aortic dissection risk, it is unknown if the presence of BAV is associated with an increased aortic risk in patients with an FBN1 gene mutation. Milleron and associates evaluated aortic diameters, aortic valve function, aortic shape and aortic events during follow-up in 1437 patients with an FBN1 gene mutation, 26 of whom (1.8%) had a BAV.

Patients with BAV had a larger aortic root maximal diameter and normalized Z score at all ages compared with patients with tricuspid aortic valve. Patients with BAV were more likely to have prophylactic aortic root surgery at a younger age, although the aortic diameter threshold was similar in the two groups. No aortic dissection was seen in patients with BAV.

In patients with a FBN1 mutation, BAV is associated with larger aortic root diameter, with no difference in evolution of Z score with age. A trend was found towards prophylactic aortic root surgery at younger ages but similar aortic diameter thresholds without occurrence of aortic dissection. This study found no evidence for lowering aortic diameter thresholds for prophylactic root surgery in the presence of BAV in patients with FBN1 mutations.