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BACKGROUND Subclinical leaflet thrombosis, characterized by hypoattenuated leaflet thickening (HALT) and reduced leaflet motion observed on 4-dimensional computed tomography (CT), may represent a form of bioprosthetic valve dysfunction.OBJECTIVES The U.S. Food and Drug Administration mandated CT studies to understand the natural history of this finding, differences between transcatheter and surgical valves, and its association with valve hemodynamics and clinical outcomes.METHODS The PARTNER 3 (The Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low-Risk Patients With Aortic Stenosis) CT substudy randomized 435 patients with low-surgical-risk aortic stenosis to undergo transcatheter aortic valve replacement (n = 221) or surgery (n = 214). Serial 4-dimensional CTs were performed at 30 days and 1 year and were analyzed independently by a core laboratory.RESULTS The incidence of HALT increased from 10% at 30 days to 24% at 1 year. Spontaneous resolution of 30-day HALT occurred in 54% of patients at 1 year, whereas new HALT appeared in 21% of patients at 1 year. HALT was more frequent in transcatheter versus surgical valves at 30 days (13% vs. 5%; p = 0.03), but not at 1 year (28% vs. 20%; p = 0.19). The presence of HALT did not significantly affect aortic valve mean gradients at 30 days or 1 year. Patients with HALT at both 30 days and 1 year, compared with those with no HALT at 30 days and 1 year, had significantly increased aortic valve gradients at 1 year (17.8 +/- 2.2 mm Hg vs. 12.7. +/- 0.3 mm Hg; p = 0.04).CONCLUSIONS Subclinical leaflet thrombosis was more frequent in transcatheter compared with surgical valves at 30 days, but not at 1 year. The impact of HALT on thromboembolic complications and structural valve degeneration needs further assessment. (J Am Coll Cardiol 2020;75:3003-15) (c) 2020 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).

Background Combined heart and kidney transplantation ( HKT x) is performed in patients with severe heart failure and advanced renal insufficiency. We analyzed the long‐term survival after HKT x, the influence of age and dialysis status, the rates of cardiac rejection, and the influence of sensitization. Methods and Results From June 1992 to December 2016, we performed 100 HKT x procedures. We compared older (≥60 years, n=53) with younger (50%, and compared these survival rates with those from the United Network for Organ Sharing database. There was no difference in 15‐year survival between the 2 age groups (35±12.4% and 49±17.3%, ≥60 versus P =0.45). There was no difference in 15‐year survival between the dialysis and nondialysis groups (44±13.4% and 37±15.2%, P =0.95). Actuarial freedom from any cardiac rejection ( acute cellular rejection >0 or antibody‐mediated rejection >0) was 92±2.8% and 84±3.8%, acute cellular rejection (≥2R/3A) 98±1.5% and 94±2.5%, and antibody‐mediated rejection (≥1) 96±2.1% and 93±2.6% at 30 days and 1 year after HKT x. There was no difference in the 5‐year survival among recipients by sensitization status with panel‐reactive antibody levels 50% (82±5.9%, 83±10.8%, and 92±8.0%; P =0.55). There was no difference in 15‐year survival after HKT x between the United Network for Organ Sharing database and our center (38±3.2% and 40±10.1%, respectively; P =0.45). Conclusions HKT x is safe to perform in patients 60 years and older or younger than 60 years and with or without dialysis dependence, with excellent outcomes. The degree of panel‐reactive antibody sensitization did not appear to affect survival after HKT x.

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.

Over the last two decades, the radial artery (RA) has become a routinely used conduit for coronary artery bypass graft surgery. One potential disadvantage of the radial artery is its higher susceptibility to vasospasm compared with other arterial grafts. We investigated whether adventitial dissection of the radial artery can reduce vasoconstriction and increase free blood flow.Following harvesting, the adventitia of the radial artery was dissected using coronary scissors. Surplus distal radial artery segments (n = 35) with and without adventitial dissection of patients undergoing coronary artery bypass surgery were collected and pairwise assessment of vasoreactivity to potassium chloride, U46619 and acetylcholine was performed in organ bath experiments. Free blood flow was measured before and after adventitial dissection.Full curve and maximal vasoconstriction of the RA to potassium chloride (P = 0.015 and 0.001) and U46619 (P = 0.048 and 0.001) was significantly reduced after adventitial dissection compared with non-adventitial dissected radial arteries. Endothelium-dependent relaxation to acetylcholine of adventitial dissected radial arteries was significantly increased (P = 0.006) compared with non-adventitial dissected radial arteries. Maximal vasorelaxation to acetylcholine was significantly increased for adventitial dissected radial arteries compared with non-adventitial dissected radial arteries (P = 0.018). Free blood flow was significantly increased after adventitial dissection (P = 0.037).The adventitial dissected radial artery is less susceptible to vasoconstriction and more prone to vasorelaxation ex vivo and shows an increased free blood flow. Therefore, we suggest adventitial dissection of the radial artery graft to reduce vasospasm for arterial revascularization in coronary artery bypass surgery.

Objective The study objective was to review our first 300 consecutive robotic-assisted mitral repairs performed from June 2005 to October 2012 and to compare the surgical outcomes of our previously reported initial 120 cases with the subsequent 180 procedures. Methods Our initial 120 robotic-assisted mitral repairs were previously reported, and we now compare our early experience with the recent 180 consecutive procedures for a total of 300 robotic-assisted mitral repairs. There was no patient selection. Every patient in need of isolated mitral valve repair underwent this procedure. All patients received an annuloplasty band and 1 or more of the following: leaflet resection, secondary chordal transposition, or polytetrafluoroethylene neochordal replacement and edge-to-edge repair. Results All 300 patients had preoperative echocardiographic findings of severe mitral regurgitation. There were no differences ( P = not significant) between the initial and the recent cohorts for preoperative characteristics, including age (58.4 ± 10.5 years vs 59.9 years), female gender (35.8% vs 36.1%), ejection fraction (61.9% vs 60.6%), congestive heart failure (35.0% vs 36.7%), creatinine (0.94 mg/dL vs 0.98 mg/dL), and New York Heart Association class. The incidence of anterior and posterior leaflet prolapse was similar in both groups, whereas Barlow syndrome was higher in group 2 (5.8% vs 27.8%). There was 1 (0.33%) hospital mortality and no deaths in the last 180 cases. Overall, 8 patients (2.7%) required subsequent mitral valve replacement via a median sternotomy, 6 (5.0%) in the first group and 2 (1.1%) in the second group ( P = .06). One patient in each group had mitral valve re-repair through a right mini-thoracotomy, and 1 patient in the first group required a mitral valve replacement via a mini-thoracotomy during the original procedure. Two of the 180 patients had documented cerebrovascular accident, but both fully recovered clinically. There was no cerebrovascular accident in the last 120 patients. Crossclamp times decreased from 116 minutes to 91 minutes in the second group despite starting a training program with a junior associate performing part of the procedure at the console in the last 100 cases. Post-pump echocardiograms showed no/trace mitral regurgitation in 86.1% of the last 180 patients and mild mitral regurgitation in 11.1%. Follow-up echocardiography for the last 180 patients from 1 month to more than 1 year showed no/trace mitral regurgitation in 64.6% of patients and mild mitral regurgitation in 23.1% of patients. Seven patients (10.8%) had moderate mitral regurgitation, and 1 patient (1.5%) had severe mitral regurgitation. Conclusions The majority of complications and reoperations occurred early in our experience, especially using the first-generation da Vinci robot (Intuitive Surgical Inc, Sunnyvale, Calif). The newer da Vinci Si HD system with the addition of an adjustable left atrial roof retractor together with increased experience has made robotic-assisted mitral repair of all types of degenerative mitral valve pathology reproducible. The training of young surgeons in a stepwise fashion in high-volume centers will help to avoid the complications encountered during the introduction of this technology.

Objectives: Combined heart-kidney transplantation with allografts from the same donor has been long proved to be a feasible approach for selected patients with coexisting end-stage cardiomyopathy and renal disease. The purpose of this retrospective study is to analyze our long-term results and compare these results with heart-only transplantation over a 7-year period. Methods: Between June 1992 and April 1999, 10 patients underwent combined heart-kidney transplantation at Cedars-Sinai Medical Center. They were all men from 44 to 70 years old (mean age, 59 ± 8.3 years) who had a mean left ventricular ejection fraction of 19.4% ± 5.0% (range, 9%-25%) and a mean creatinine clearance of 25.4 mL/min (range, 10-39 mL/min). Four patients underwent pretransplantation dialysis. Results: There was no operative mortality. The actuarial survival at 1, 2, and 5 years was 100%, 88% ± 11.7%, and 55% ± 20.1%, respectively. By comparison, the operative mortality of 169 patients who underwent heart-only transplantation during the same time interval was 2.4%, with an actuarial survival at 1, 2, and 5 years of 92% ± 2.1%, 84% ± 2.8%, and 71% ± 3.9%, respectively (P = .37). Eight patients showed no evidence of significant (≥1B) cardiac allograft rejection postoperatively, and the actuarial freedom from rejection at 30 days, 1 year, and 2 years was 90% ± 9%, 80% ± 13%, and 80% ± 13%, respectively. Renal allograft survival was 90% at 1 and 2 years. Conclusions: Combined heart-kidney transplantation yields satisfactory long-term results similar to those for heart-only transplantation, with a low incidence of cardiac allograft rejection and renal allograft survival when both allografts are from the same donor. This approach effectively expands the selection criteria for heart-only and kidney-only transplantation in potential candidates with coexisting end-stage cardiac and renal disease.

BackgroundComplete revascularization has been the standard for coronary bypass grafting. However, surgical intervention has evolved with increasing use of arterial conduits and off-pump techniques.MethodsPatients undergoing non-redo bypass surgery from January 1998 through December 2000 were followed up with questionnaires and telephone contact. Incomplete revascularization was defined as absence of bypass grafts placed to a coronary territory supplied by a vessel with 50% or greater stenosis.ResultsOne thousand thirty-four patients were followed for a mean of 3.3 ± 1.6 years. Complete revascularization was found in 937 (90.6%) patients, and incomplete revascularization was found in 97 (9.4%) patients. Eight hundred twenty-seven (80.4%) patients underwent on-pump operations, and 207 (19.6%) underwent off-pump operations. Incomplete revascularization was more prevalent in off-pump versus on-pump operations (21.7% vs 6.3%, P < .001). Multivariable Cox regression analysis indicated that in-hospital cerebrovascular accidents (hazard ratio, 5.49; P < .001), chronic obstructive pulmonary disease (hazard ratio, 1.97; P = .019), and incomplete revascularization (hazard ratio, 1.85; P = .040) predicted an increased hazard (risk) of cardiac death. Left internal thoracic artery (hazard ratio, 0.38; P = .047), right internal thoracic artery (hazard ratio, 0.25; P = .019), and radial artery (hazard ratio, 0.36; P < .001) grafting reduced the risk of cardiac death. The 5-year unadjusted survival rate was 52.6% versus 82.4% in patients undergoing incomplete and complete revascularization (P < .001), with cardiac survival rates of 74.5% versus 93.1%, respectively (P < .001). However, this difference in cardiac survival was smaller in octogenarians with incomplete versus complete revascularizations (77.4% vs 87.6%, P = .101) and was essentially absent in off-pump versus on-pump operations if complete revascularization was achieved in both cases (93.6% vs 93.1%, P > .200).ConclusionsComplete revascularization and arterial grafting improve 5-year survival. Off-pump techniques do not affect survival. Complete revascularization should be performed whenever possible.

Objectives The purpose of this study was to compare outcomes for drug-eluting stents (DES) and coronary artery bypass graft (CABG) surgery in patients with unprotected left main coronary artery (ULMCA) stenosis. Background Expert guidelines recommend coronary artery bypass graft (CABG) surgery for the treatment of significant stenosis of the unprotected left main coronary artery (ULMCA) if the patient is eligible for CABG; however, treatment by percutaneous coronary intervention (PCI) is common. Methods Details of patients (n = 343, ages 69.9 ± 11.9 years) undergoing coronary revascularization for ULMCA stenosis (April 2003 to January 2007) were recorded. A total of 223 patients were treated with CABG (mean [interquartile range]: follow-up 600 [226 to 977) days) and 120 by PCI (follow-up 362 [192 to 586) days). The hazard ratios (HRs) for death and major adverse cardiovascular and cerebrovascular events (MACCE) were calculated incorporating propensity score adjustment. Survival comparisons were conducted in propensity-matched subjects (n = 134), and in low- and high-risk subjects for CABG. Results Patients treated by PCI were more likely to be ≥75 years of age (49% vs. 33%; p = 0.005), and of greater surgical risk (Parsonnet score 17.2 ± 11.2 vs. 13.0 ± 9.3; p l 0.001) than patients treated by CABG. Overall, the propensity-adjusted HR for death was not statistically different (HR 1.93, 95% confidence interval [CI] 0.89 to 4.19, p = 0.10), but MACCE was greater in the PCI group (HR 1.83, 95% CI 1.01 to 3.32, p = 0.05). In propensity-matched individuals, neither survival nor MACCE-free survival were different. Survival was equivalent among low-risk candidates, but PCI had a tendency to inferior survival in high-risk candidates (Ellis category IV, log-rank p = 0.05). Interaction testing, however, failed to demonstrate a difference in outcomes of the 2 revascularization techniques as a function of baseline risk assessment. Conclusions Overall, the propensity-adjusted risk of mortality for treatment of ULMCA disease does not differ between PCI- and CABG-treated groups. There appears to be sufficient equipoise that a randomized clinical trial to compare the techniques would not be ethically contraindicated.

ObjectivesThe goal of this study was to examine the impact of reasons for surgical inoperability on outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).BackgroundPatients with severe aortic stenosis may be deemed inoperable due to technical or clinical reasons. The relative impact of each designation on early and late outcomes after TAVR is unclear.MethodsPatients were studied from the inoperable arm (cohort B) of the randomized PARTNER (Placement of Aortic Transcatheter Valve) trial and the nonrandomized continued access registry. Patients were classified according to whether they were classified as technically inoperable (TI) or clinically inoperable (CLI). Reasons for TI included porcelain aorta, previous mediastinal radiation, chest wall deformity, and potential for injury to previous bypass graft on sternal re-entry. Reasons for CLI were systemic factors that were deemed to make survival unlikely.ResultsOf the 369 patients, 23.0% were considered inoperable for technical reasons alone; the remaining were judged to be CLI. For TI, the most common cause was a porcelain aorta (42%); for CLI, it was multiple comorbidities (48%) and frailty (31%). Quality of life and 2-year mortality were significantly better among TI patients compared with CLI patients (mortality 23.3% vs. 43.8%; p < 0.001). Nonetheless, TAVR led to substantial survival benefits compared with standard therapy in both inoperable cohorts.ConclusionsPatients undergoing TAVR based solely on TI have better survival and quality of life improvements than those who are inoperable due to clinical comorbidities. Both TI and CLI TAVR have significant survival benefit in the context of standard therapy. (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894)

Cardiac Catheterization Laboratory, North Shore Shore University Health System, 9669 North Ke 60076; Cardiothoracic Surgery, University of Colo Colorado 88045-2527; Cardiac Catheterization Hospital, Evanston, Illinois 60201; Cardiology Di pital, Walgreen Building 3rd Floor, Evanston, Illinoi Washington School of Medicine, Seattle, Washin Regional Heart Center, 1959 NE Pacific, Box 356171 98195; Rush Center for Congenital & Structural H Illinois 60612; Pediatric Cardiology, Rush Unive Chicago, Illinois 60612; Peter Munk Cardiac Cen Hospital, Toronto, Ontario M5G2C4; Saint Vincent Medical Center/Fallon Clinic, Worcester, Massach medical Associates, Northborough, Massachusetts; Center, Los Angeles, California 90048; Departmen Health & Science University, 2761 SW Patton Ct., Po Lenox Hill Heart and Vascular Institute of New York 10021; Division of Cardiothoracic Surgery, delphia, Pennsylvania 19104; Cardiovascular C Hospital Baylor Plano, Plano, Texas 75093; The Da Broccoli Center for Aortic Diseases, The John

There is a paucity of data of patients with severe functional mitral regurgitation (FMR) not treated with surgery. There is no data supporting surgery affects outcome in FMR. The MitraClip is a less invasive procedure, which may improve survival. As off September 2012, all consecutive FMR patients

MitraClip (Abbott Vascular, Menlo Park, California) is an effective low risk transcatheter treatment option for the treatment of functional mitral regurgitation (FMR). Pulmonary hypertension (PH) is a predictor of adverse outcome following mitral valve surgery. However, the prognostic implications

a degenerative MR patient after 3.2 years. There were no strokes with an average follow-up of 2.4 1.8 years. There were sustained improvements in New York Heart Association class (from 2.8 0.6 to 1.6 0.5, p