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Guideline-directed medication adherence is considered an important quality measure after cardiac surgery. We evaluated compliance with the American College of Cardiology/American Heart Association guidelines for warfarin use after surgical aortic valve replacement (sAVR) using bioprostheses and examined potential variations in anticoagulation practice over time.Using the OptumLabs Data Warehouse, we investigated adult patients having bioprosthetic sAVR with or without coronary artery bypass (2007-2019). Early postoperative warfarin use was defined as ≥30 days of continuous prescription coverage after sAVR.Among 10 730 adult patients having sAVR, 3071 (28.6%) received warfarin early postoperatively. Median length of warfarin prescription coverage was 4.5 months (interquartile range, 3.0-8.9 months). However, only 11.1% (736/6634) had warfarin prescription coverage of 3 to 6 months in compliance with the most recent guidelines. Yearly warfarin prescription rate did not change significantly during the 13-year period (P = .386). Compared with patients from the non-warfarin group, those receiving warfarin prescriptions were older and more likely to be male and to have atrial fibrillation, congestive heart failure, chronic pulmonary disease, and CHAAnticoagulation after sAVR as reflected by warfarin prescriptions may be underused; the rates of warfarin use have not changed in the last decade. Although additional studies are needed to confirm the benefit of early anticoagulation after sAVR, these results indicate that guideline recommendations are not followed by most clinicians. The findings highlight a potentially important area for quality improvement.

The prevalence and impact of atrial fibrillation (AF) versus sinus rhythm (SR) on outcomes in very severe aortic stenosis (vsAS) of the native valve is unknown. The aim of the study was to determine the prognostic significance of AF in vsAS. A total of 563 patients with vsAS (transaortic valve peak velocity ≥5 m/s) and left ventricular ejection fraction ≥50% were identified retrospectively. Patients were divided by rhythm at the time of index transthoracic echocardiogram (AF: n = 50 [9%] vs SR: n = 513 [91%]). Patients with AF were older (83.1 ± 7.5 vs 72.5 ± 12.2 y, p0.001) and had no difference in gender distribution (p = 0.49) but had a higher Charlson co-morbidity index (2 [1,3] vs 1 [0,2], p = 0.01). There was no difference in transaortic peak velocity (5.3 ± 0.3 m/s vs 5.4 ± 0.4 m/s, p = 0.13) and left ventricular ejection fraction was comparable (63 ± 7 vs 66 ± 7%, p = 0.01). Age-, gender-, Charlson co-morbidity index-, and time-dependent aortic valve replacement (AVR)-adjusted overall mortality at 5 years was significantly higher in patients with AF than patients with SR (hazard ratio [HR] 1.88 [1.23 to 2.85], p = 0.003). AVR was associated with improved survival (HR = 0.30 [0.22 to 0.42], p0.001), with no statistically significant interaction of AVR and rhythm (p = 0.36). Outcomes were also compared in the 2 SR:1 AF propensity-matched analyses (100 SR: 50 AF), with matching done according to age, gender, clinical co-morbidities, and year of echocardiogram. In the propensity-matched analysis, age-, gender-, and time-dependent AVR-adjusted all-cause mortality was higher in AF (HR 2.32 [1.41 to 3.82], p0.001). In conclusion, AF was not uncommon in vsAS and identified a subset of patients at a much higher risk of mortality without AVR.

Surgical aortic valve replacement with coronary artery bypass grafting (SAVR+CABG) is the recommended treatment for aortic stenosis and coronary artery disease; however, percutaneous coronary intervention at the time of transcatheter aortic valve replacement (TAVR+PCI) is used with increasing frequency.Using the National Inpatient Sample, we identified all adult admissions with a diagnosis of aortic stenosis. Subgroups of SAVR+CABG and TAVR+PCI formed the study group. Outcomes of interest included total hospitalization charges, temporal trends, in-hospital mortality, and complications.Between 2012 and 2017, a total of 97 955 admissions (95.9%) received SAVR+CABG, and 4240 (4.1%) received TAVR+PCI; the proportion of TAVR+PCI increased from 1% in 2012 to 9.2% in 2017 (P.001). Compared with patients receiving TAVR+PCI, admissions receiving SAVR+CABG were younger, more likely to be male, and had lower comorbidity (all P.001). Adjusted in-hospital mortality was comparable in both groups (odds ratio 0.94; 95% confidence interval, 0.79 to 1.11; P = .45). Higher rates of pacemaker implantation, cardiac arrest, and vascular complications were seen in the TAVR+PCI group, whereas SAVR+CABG was associated with a greater requirement for prolonged ventilation. Admissions receiving TAVR+PCI had shorter lengths of hospital stay and were more likely to be discharged home. Nevertheless, the TAVR+PCI group had higher hospitalization charges compared with the SAVR+CABG group (all P.001).There has been a steady increase in the use of percutaneous strategies for aortic stenosis and coronary artery disease management. In-hospital mortality was comparable in SAVR+CABG and TAVR+PCI groups, but despite shorter in-hospital stays, TAVR+PCI was associated with higher cardiac and vascular complication rates and hospitalization charges.

Enlargement of the sinus of Valsalva (SOV) is common in patients with bicuspid aortic valves (BAVs), and management at the time of aortic valve replacement (AVR) and concomitant ascending aorta replacement/repair is controversial.Between January 2000 and July 2017, 400 patients with BAVs underwent AVR and concomitant ascending aorta repair (graft replacement, 79%; aortoplasty, 21%). To assess the impact of the initial SOV dimension on future dilatation and outcomes, patients were stratified into 2 groups: SOV of less than 40 mm (SOV40 mm) (n = 209) and SOV of 40 mm or larger (SOV≥40 mm) (n = 191).Patients with SOV≥40 mm were older and more often male. At a median follow-up of 8.1 years (interquartile range, 7.4-9.1 years), 6 patients underwent reoperations on the ascending or sinus portion of the aorta due to aneurysmal dilatation, and enlargement of the sinus was the primary indication for operation in 1 patient. Adjusted analysis showed that baseline SOV and SOV dimension over time were not associated with late outcomes. A gradual increase in SOV diameter over time was identified (P = .004). Patients with smaller baseline SOV diameters showed an initial early decrease in diameter, followed by gradual increase, whereas those with larger baseline diameters had a stable early phase, followed by gradual dilatation.Ascending aorta replacement may lead to an initial remodeling/stabilizing effect on the spared bicuspid aortic root, which is more pronounced in patients with lower SOV diameters. In addition, our data demonstrate that the retained aortic sinuses enlarge slowly, and within the limited follow-up of our study, SOV diameter was not a risk factor for survival or reoperation.

Background The anomalous circumflex coronary artery (ACCA) from the right coronary artery or sinus of Valsalva lies in proximity to the aortic valve annulus. This study sought to determine the prevalence of injury to the ACCA during surgical aortic valve replacement (SAVR). Methods We queried the databases of the Departments of Cardiovascular Surgery and Cardiovascular Diseases of Mayo Clinic, Rochester, Minnesota for all patients who underwent SAVR in the setting of an ACCA. The study investigators identified 31 patients operated on from September 2002 through December 2018. The end point was myocardial ischemia in the distribution of the ACCA. Results The patients’ mean age was 69 ± 11 years, sex was female in 8 patients (26%), and ejection fraction was 62% (interquartile range, 59% to 68%). No patient underwent exploration of the ACCA, but 5 (16%) had a coronary artery bypass graft to the ACCA. No patient demonstrated myocardial infarction or underwent perioperative intervention on the ACCA; however, discharge echocardiography showed new lateral wall motion abnormality in 5 (16%) patients that was associated with a reduction in ejection fraction of −11% from baseline (P = .007). Coronary artery bypass graft to the ACCA was not protective of new lateral wall motion abnormality (P = .968). Mortality was 34% ± 10% at 10 years and was not associated with new lateral wall motion abnormality (log-rank test P = .183). Conclusions Clinically apparent myocardial infarction was not identified after SAVR, but echocardiographic evidence of myocardial ischemia in the distribution of the ACCA was identified in 16% of patients. Protective adjuvant intervention on the ACCA may be indicated. Further study is warranted.

Background Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR). Methods Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography. Results Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76–86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm2/m2 [IQR, 0.39–0.47 cm2/m2] vs 0.46 cm2/m2 [IQR, 0.41–0.51 cm2/m2], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P Conclusions AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.

Long-term outcomes of mitral valve surgery after mediastinal radiation therapy (MRT) are not well characterized. We analyzed long-term survival in patients who underwent mitral valve repair or replacement after MRT. From 2001 to 2018, 148 patients underwent mitral valve surgery at our institution after MRT for cancer. The association between surgery group and survival was assessed using Cox proportional hazards modeling, with propensity score adjustment to control for clinical and operative differences between groups. Mitral valve was repaired in 48 (32.4%) and replaced in 100 (67.6%) patients. The groups (repair vs replacement) were similar in age (62.0 vs 57.1 years, p = 0.10), gender (female n = 38, 79.2% vs n = 65, 65%, p = 0.08), chronic lung disease (n = 12, 25.0% vs n = 37, 37.0%, p = 0.19), congestive heart failure (n = 13, 27.1% vs n = 38, 38.4%, p = 0.20), but differed in atrial fibrillation (n = 17, 35.4% vs n = 13, 13.0%, p = 0.002), first cardiovascular surgery (n = 34, 70.8% vs n = 47, 47.0%, p = 0.006), and time since MRT (median 12, 7-27 years, vs 30, 19-37 years, p0.001). Long term survival was no different between groups in the unadjusted (p = 0.835) and propensity-adjusted (p = 0.645) analysis, and inferior to the expected survival of an age- and sex-matched population. Mediastinal irradiation negatively impacts survival in patients who undergo mitral valve surgery. The traditional advantage of mitral valve repair over replacement on long-term survival was not seen in patients with radiation associated mitral valve disease.

Objectives The phenomenon of systolic anterior motion (SAM) of the mitral valve (MV) was discovered 50 years ago, but to date only a few studies have identified risk factors for SAM following mitral repair. There are limited data on the necessity of surgical reintervention on the MV once SAM is discovered by intraoperative transesophageal echocardiography. We sought to identify predictors of SAM in a large cohort of consecutive patients, assess the rate of early reintervention on the MV to address SAM, and follow the progression of SAM postdischarge. Methods Analysis of electronically stored echocardiographic exams of adults who underwent MV repair in a recent decade. Results Following MV repair, the incidence of SAM immediately after cardiopulmonary bypass was 13% (98 of 761 patients). Multivariable analysis revealed several preoperative risk factors of SAM development and progression, including a lower ratio of anterior to posterior leaflets heights, younger age, lower end-systolic left ventricular volume, presence of bileaflet prolapse, and male sex. SAM was managed conservatively in 91 patients (93%) and surgically in 7 patients (7%). In a majority of patients (70 of 98 patients [71%]) SAM resolved before hospital discharge. Conclusions Transesophageal echocardiography findings associated with SAM were excessive height of posterior to anterior mitral leaflet, smaller left ventricular end-systolic volume, and bileaflet prolapse. Conservative management of SAM was usually successful, and persistent hemodynamically significant SAM was uncommon. Prophylactic modification of the surgical technique to avoid SAM seems unnecessary for all but those at highest risk for developing SAM.

To evaluate outcomes of elective surgical management of tricuspid regurgitation (TR) in patients with transvenous right ventricular leads, and compare results between non-lead-induced and lead-induced TR patients.We studied patients with right ventricular leads who underwent tricuspid valve surgery from January 1, 1993, through December 31, 2015, and categorized them as non-lead-induced and lead-induced TR. Propensity score (PS) for the tendency to have lead-induced TR was estimated from logistic regression and was used to adjust for group differences.From the initial cohort of 470 patients, 444 were included in PS-adjustment analyses (174 non-lead-induced TRs [123 repairs, 51 replacements], 270 lead-induced TRs [129 repairs, 141 replacements]). In PS-adjusted multivariable analysis, lead-induced TR was not associated with mortality (P=.73), but tricuspid valve replacement was (hazard ratio, 1.59; 95% CI, 1.13 to 2.25; P=.008). Five-year freedom from tricuspid valve re-intervention was 100% for non-lead-induced TR and 92.3% for lead-induced TR; rates adjusted for PS differed between groups (P=.005). There was significant improvement in TR postoperatively in each group (P.001). In patients having tricuspid valve repair, TR grades tended to worsen over time, but the difference in trends was not significantly different between groups.Lead-induced TR did not affect long-term survival after elective tricuspid valve surgery. In patients with lead-induced TR, tricuspid valve re-intervention was more common. Improvement in TR was achieved in both groups after surgery; however, severity of TR tended to increase over follow-up after tricuspid valve repair.

Hyponatremia is an unrecognized risk factor for adverse outcomes after cardiac surgery. We sought to study the prevalence of preoperative hyponatremia and its impact on short-term and long-term outcomes after cardiac surgery.Patients who had coronary artery bypass graft, valve, or coronary artery bypass graft and valve procedures from 2000 to 2016 and available preoperative serum sodium values within 30 days of the index procedure were included in the study. The effect of preoperative sodium on short-term and long-term outcomes was analyzed as a continuous and binary (hyponatremia [Na+135 mEq/L] versus no hyponatremia) predictor variable in multivariable regression models.Preoperative hyponatremia was present in 9.9% of 16,238 patients with available sodium levels. Comorbidities were more common in patients with hyponatremia. Hyponatremia was independently associated with operative mortality (odds ratio [OR] = 1.80; 95% confidence interval [CI], 1.38-2.34; P.001), long-term mortality (hazard ratio = 1.31; 95% CI, 1.21-1.40; P .001), longer postoperative length of stay (hazard ratio = 1.35; 95% CI, 1.28-1.43; P.001), renal failure (OR = 1.52; 95% CI, 1.20-1.93; P.001), prolonged ventilation use (OR = 1.52; 95% CI, 1.30-1.78; P.001), and stroke or transient ischemic attack (OR = 1.48; 95% CI, 1.09-2.02; P = .013). Severity of hyponatremia, as measured by sodium level, was similarly associated with increased risk for death and postoperative complications.Preoperative hyponatremia is relatively common and is associated with adverse short-term and long-term outcomes after cardiac surgery. Preoperative hyponatremia can be used independently from standard risk factors to identify high-risk patients for cardiac surgery.

Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are at higher risk of aortic stenosis. Data regarding transcatheter aortic valve implantation (TAVI) in these patients are limited. Herein, we aim to investigate TAVI outcomes in patients with ESKD and CKD. We analyzed clinical data of patients with ESKD and CKD who underwent TAVI from 2008 to 2018 in a large urban healthcare system. Patients' demographics were compared, and significant morbidity and mortality outcomes were noted. Multivariable analyses were used to adjust for potential baseline variables. A total of 643 patients with CKD underwent TAVI with an overall in-hospital mortality of 5.1%, whereas 84 patients with ESKD underwent TAVI with an overall mortality rate of 11.9%. The most frequently observed comorbidities in patients with CKD were heart failure, atrial fibrillation (AF), mitral stenosis (MS), pulmonary hypertension, and chronic lung disease. After multivariable analysis, MS (adjusted odds ratio (OR) 3.92; 95% confidence interval (CI) 1.09 to 11.1, p

Previous studies suggest that patients with prior or current hematologic malignancy are at increased risk of intraoperative and postoperative complications when undergoing cardiac surgery. The aim of this review was to compare clinical outcomes of patients with a history of hematologic malignancy to those of similar patients with no known blood dyscrasia.From January 1993 to June 2017, 37,839 patients underwent elective cardiac surgery at Mayo Clinic. We matched 612 patients (1.6%) with a history of hematologic malignancy to 612 controls, and compared operative details, early postoperative complications, and late survival.The median age of matched patients with hematologic malignancy was 71 years (interquartile range [IQR], 62 to 77) and 71 years (IQR, 62 to 77) for patients without cancer. Patients with prior diagnosis of malignancy had lower hemoglobin levels, 12.8 (IQR, 11.5 to 13.8) vs 13.5 (IQR, 12.2 to 14.6; P.001), but similar platelet counts, 195 (IQR, 147 to 263) vs 203 (IQR, 170 to 245; P = .533). Patients with malignancy were at greater risk of receiving postoperative blood transfusions (47.4% vs 35.6%, P.001). However, reoperations for postoperative bleeding (4.7% vs 3.3%, P = .253) and stroke (1.3% vs 1.3%, P.999) were similar. Thirty-day mortality was 3.3% among patients with hematologic malignancy and 1.5% among matched controls (P = .061). Overall survival among patients with cancer was reduced (P.0001).Although late survival is reduced in patients with hematologic malignancies, early outcomes are generally similar to those of matched controls. Therefore, surgery should not be withheld from patients with a diagnosis of hematologic malignancy who would benefit from cardiac procedures.

Background/purpose Machine learning has been used to predict procedural risk in patients undergoing various medical interventions and procedures. One-year mortality in patients after Transcatheter Aortic Valve Replacement (TAVR) has a wide range (from 8.5 to 24% in various studies). We sought to apply machine learning to determine predictors of one year mortality in patients undergoing TAVR. Methods/materials A retrospective study of 1055 patients who underwent TAVR (Jan 2014–June 2017) with one-year follow up was completed. Baseline demographics, clinical, electrocardiography (ECG), Computed Tomography (CT) and echocardiography data were abstracted. Variables with near zero variance or ≥50% missing data were excluded. The Gradient Boosting Machine learning (GBM) prediction model included 163 variables and was optimized using 5-fold cross-validation repeated 10-times. The receiver operator characteristic (ROC) for the GBM model was calculated to predict one-year mortality post TAVR, and then compared to the TAVI2-SCORE and CoreValve score. Results Among 1055 TAVR patients (mean age 80.9 ± 7.9 years, 42% female), 14.02% died at one year. 78% had balloon expandable valves placed. Based on GBM, the ten most predictive variables for one-year survival were cardiac power index, hemoglobin, systolic blood pressure, INR, diastolic blood pressure, body mass index, valve calcium score, serum creatinine, aortic annulus area, and albumin. The area under ROC to predict survival for the GBM model vs TAVI2-SCORE and CoreValve Score was 0.72 (95% CI 0.68–0.78) vs 0.56 (95%CI 0.51–0.62) and 0.53 (95% CI 0.47–0.59) respectively with p Conclusion The GBM model outperforms TAVI2-SCORE and CoreValve Score in predicting mortality one-year post TAVR.

There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes.We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients.The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time.Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

There is controversy on how to address mild aortic root dilation during concomitant aortic valve replacement: composite aortic valve conduit replacement or separate ascending aorta and aortic valve replacement. We reviewed our experience to address the issue.We retrospectively reviewed 778 adult nonsyndromic patients with aortic root diameter 55 mm or less who received replacement of the ascending aorta and aortic valve from January 1994 to June 2017. Patients were divided into 2 groups based on the type of aortic root intervention: composite aortic valve conduit replacement in 406 patients (52%) and separate ascending aorta and aortic valve replacement in 372 patients (48%). Propensity matching was used to mitigate differences in baseline patient characteristics and produced 188 matched pairs.Sinus of Valsalva diameter was 43 mm (39-47). Operative mortality occurred in 3 patients (2%) in the composite aortic valve conduit replacement group and in 5 patients (3%) in the separate ascending aorta and aortic valve replacement group (P = .470). Median follow-up was 9.6 years (8.4-10.1). Long-term mortality was similar in the 2 groups (P = .083). Repeat operation was performed in 13 patients (7%) in the composite aortic valve conduit replacement group and in 19 patients (10%) in the separate ascending aorta and aortic valve replacement group (P = .365). Sinus of Valsalva diameter decreased 2 mm (-4-0; median follow-up 41 months) in the propensity-matched separate ascending aorta and aortic valve replacement group.In patients with mild aortic root dilation, separate ascending aorta and aortic valve replacement results in a similar risk of repeat operation and mortality in comparison with composite aortic valve replacement. Separate ascending aorta and aortic valve replacement is not associated with subsequent aortic root dilation on medium-term echocardiography follow-up.

Background Geographic origin is cited as a possible factor influencing outcomes of operation for repair or replacement of degenerative mitral valve (MV) disease. Our study aimed to identify the potential impact of referral bias on clinical outcomes of MV surgery. Methods We analyzed clinical and echocardiographic information of 2353 patients undergoing primary or secondary MV surgery for degenerative MV disease. Patients were grouped as local (in-state), regional (5 surrounding states), or national referrals. Results The number of patients (local, 827; regional, 809; national, 717) and median follow-up time (9.1 years) were similar between geographic groups. More comorbidities were found in the local patient group. Overall operative risk was 0.7% and was greater in local and regional patients compared with national patients (0.7% and 1.1% vs 0.1%, P = .05). Valve repair was performed in 97% of isolated MV surgeries, and repair rate was similar in the 3 geographic groups. The 3 groups had similar incidences of major morbidity, but local and regional groups had higher 30-day readmissions. In univariate analysis, survival was improved in national and regional patients compared with local patients; however in multivariable analysis this difference was no longer significant. Conclusions There were important variations in baseline demographic and clinical characteristics between referral groups; local and regional patients presented with more comorbid conditions compared with national referrals. Aside from a small difference in perioperative mortality, early outcomes were generally similar. Late survival, however, was superior in national patients, and this referral bias is explained by fewer associated medical illnesses.

Cardiac power to left ventricular mass (LVM) ratio, also termed cardiac efficiency (CE), reflects the rate of cardiac work delivered to the potential energy stored in LVM. We sought to assess the association between baseline resting CE and survival post transcatheter aortic valve replacement (TAVR).We retrospectively extracted data of patients who received TAVR in the Mayo Clinic Foundation with follow up data available at 1 year. Cardiac output was measured using Doppler echocardiography at baseline. CE was calculated using the formula, (cardiac output × mean arterial blood pressure)/(451 × LVM × 100) W/100 g. Survival score analysis was performed to identify cut off value for CE to identify the maximum difference in mortality in the study cohort. Patients were subsequently divided into 2 groups CE 0.38 W/100 g and CE ≥ 0.38 W/100 g. Survival was determined using Kaplan-Meier method.We included 954 patients in the final analysis. CE in group1 vs group 2 was 0.31 ± 0.05 W/100 g vs 0.59 ± 0.18 W/100 g. Patients in group1 were more likely to be male, had a higher prevalence of atrial fibrillation, prior myocardial infarction, mitral and tricuspid regurgitation. They also had a higher STS risk score, NYHA functional class, and lower aortic valve area. The remainder of the baseline characteristics was similar in both groups. A lower CE was associated with higher 1-year mortality following TAVR based on multivariate analysis. (Group1: 22.18% vs Group 2: 9.89%, p .0001).In our cohort, a low baseline CE (0.38 W/100 g) conferred higher mortality risk following TAVR.

Obstructive sleep apnea (OSA) is associated with increased risk of postoperative complications in noncardiac surgery, with limited literature on cardiac surgical patients. Perioperative outcomes of patients with OSA were compared with outcomes of those without OSA undergoing cardiac surgery.This was a retrospective single-center cohort study of adults who underwent cardiac surgery from January 2010 to April 2017. Outcomes of patients with OSA were compared with those without OSA, including length of stay, readmissions, hospital death, and short-term outcomes.OSA was present in 2636 of 8612 patients (30.6%) identified during the study period with OSA. Patients with OSA had a longer median length of stay (6 vs 5 days, P.001), longer incidence of prolonged (7 days) length of stay (26.3% vs 23.0%, P.001), and were less likely to be discharged to home (78.2% vs 84.4%, P.001). OSA patients also had a higher 30-day readmission rate (14.7% vs 10.4%, P.001). Acute kidney injury was more common in OSA patients (25.2% vs 19.9%, P.001). Our multivariable model found postoperative atrial fibrillation was associated with older age and not OSA status (age50 years compared with75 years; odds ratio, 4.10; 95% confidence interval, 3.39-4.96).OSA patients had a longer mean length of stay, were more likely to have a prolonged length of stay, more likely to be discharged to a location other than home, and had a higher 30-day readmission rate. This suggests higher resource utilization is required to care for OSA patients after cardiac surgery.

To evaluate expansion of degenerative thoracic aortic aneurysms (TAAs) and compare results between ascending and descending TAAs.Among patients with diagnosis of degenerative TAA (1995-2015) in Olmsted County, we studied those having at least 2 computed tomography scans of TAA throughout the follow-up. Patients were classified as ascending or descending groups according to the segment where the maximal aortic diameter was measured. Primary end points were expansion rates and factors associated with TAA growth.We investigated 137 patients, 70 (51.1%) of whom were women; 78 (56.9%) were in the ascending and 59 (43.1%) were in the descending group. Median baseline maximal aortic diameter was 48.5 mm (interquartile range, 47.0-49.9 mm) for ascending and 42.4 mm (interquartile range, 40.0-45.4 mm) for descending group (P .001). Median expansion rate was higher in the descending than the ascending group (2.0 mm/year [interquartile range, 0.9-3.2 mm/year] vs 0.2 mm/year [IQR, 0.1-0.6 mm/year]; P .001). Aneurysm in the descending aorta and larger baseline maximal aortic diameter were independently associated with TAA expansion. Advanced age and chronic obstructive pulmonary disease but not aneurysm size or location were independently associated with overall mortality (P .05). Aneurysm in the descending aorta was associated with aortic-related events (P .05).Degenerative TAAs under surveillance expand slowly. Descending TAA and larger baseline maximal aortic diameter were independently associated with more rapid TAA expansion, but these factors did not influence all-cause mortality.

Little information exists regarding the use of arch operations for repair of acute type A aortic dissections (AADs) despite increasing interest in this strategy and its potential impact on outcomes. We aimed to determine the relationship between extent of aortic repair, US geographic regions, and outcome.We queried The Society of Thoracic Surgeons database for patients who underwent AAD repair from January 1, 2004 to December 31, 2016 and grouped patients by ascending-only operations and operations involving the arch.We identified 25,462 patients (mean age, 59.8 ± 14.2; 66.7% men) who underwent AAD repair. Operations involving the ascending aorta only were performed in 54% of patients; 46% had repair additionally involving the arch. The 30-day mortality was 18.9% for patients who underwent ascending-only operations vs 19.8% for patients who underwent arch operations (P = .09). In multivariable analysis older age (P.001), earlier year of operation (P.001), diabetes mellitus (P.001), severe chronic lung disease (P.001), prior cerebrovascular disease (P.001), and longer bypass time (P.001) were independently associated with 30-day mortality. There was regional variation in 30-day mortality (P.001), and incidence of arch repair varied from 38.6% to 52.6% in 9 geographic regions (P.001).In this analysis of cardiac surgical practice in the United States, repair of AADs included a portion of the aortic arch in 46% of patients. Early mortality remained high throughout the current era regardless of extent of aortic resection. Regional variation in perioperative mortality may signal an opportunity for practice improvement.

This study directly compared outcomes of transcatheter aortic valve-in-valve insertion (TAVI-in-valve) with repeat surgical aortic valve replacement (SAVR) for failing stented aortic biological prostheses.We retrospectively reviewed the records of 350 consecutive patients who underwent repeat aortic valve replacement of failing stented aortic biological valve prostheses at our institution between November 2008 and May 2018. Operations included TAVI-in-valve in 90 patients (26%) and repeat SAVR in 260 patients (74%).Patient age was 74 years (interquartile range [IQR], 65-79 years), 100 patients (29%) were women, aortic valve internal diameter was 21 mm (IQR, 19-22), Society of Thoracic Surgeons predicted operative mortality risk was 4.1% (IQR, 2.3%-6.8%), and the interval to repeat operation was 7 years (IQR, 5-11 years). A 23-mm or smaller valve was inserted in 57 patients (63%) in the TAVI-in-valve group and in 170 (65%) in the SAVR group (P = .725). Aortic root enlargement was done in 45 patients (17%) in the SAVR group. Procedure-related complications were less in the TAVI-in-valve group (23% vs SAVR 59%, P.001), whereas operative mortality was similar in both groups (2.2% vs SAVR 2.6%, P = 1.000). Severe patient-to-prosthesis mismatch was more common after TAVI-in-valve (44% vs SAVR 12%, P.001). Median duration of follow-up was 2.1 years (IQR, 1.2-4.2 years). Multivariable analysis demonstrated no association between TAVI-in-valve and intermediate-term mortality (hazard ratio, 1.18; 95% confidence interval, 0.62 to 2.22; P = .612).TAVI-in-valve and repeat SAVR can be done with similar operative and intermediate-term mortality. SAVR results in better hemodynamic function and thus appears the preferred option.

Cardiac filling pressures may be elevated due to abnormalities in the myocardium, heightened pericardial restraint, or both. The authors hypothesized that the relative contributions due to myocardium and pericardium could be estimated by the ratio between right atrial pressure and pulmonary arterial wedge pressure (RAP/PAWP), which would enable better discrimination of the extent of myocardial disease in patients with constrictive pericarditis (CP).This study investigated the relationships between RAP/PAWP and the pericardial thickness as well as echocardiographic parameters of myocardial function and assessed the prognostic implications of RAP/PAWP for long-term mortality in primary and mixed CP patients who underwent pericardiectomy.A total of 113 surgically confirmed CP patients who underwent echocardiography and cardiac catheterization within 7 days of each other between 2005 and 2013 were included in the study. The patients were classified into a high RAP/PAWP group (≥0.77; n = 56) or a low RAP/PAWP group (0.77; n = 57) according to the median RAP/PAWP value. The primary outcome was prognostic implication of RAP/PAWP on long-term mortality and assessment of the relationship between RAP/PAWP and Doppler echocardiographic parameters in primary and mixed CP. In addition, the relationship between RAP/PAWP and the pericardial thickness was assessed.RAP/PAWP was directly correlated with pericardial thickness (regression coefficient [β] = 8.34; p 0.001). RAP/PAWP had a significant direct correlation with early diastolic velocity of medial mitral annulus (e') (β = 10.69; p 0.001) and inverse relationship with early transmitral diastolic velocity (E) (β = -105.15; p 0.001), resulting in an inverse relationship with the ratio of E/e' (β = -23.53; p 0.001). Patients with high RAP/PAWP ratio had a better survival rate compared with those with low RAP/PAWP ratio (p = 0.01). Its prognostic value was significant in primary CP (p = 0.03) but not in mixed CP with concomitant myocardial disease (p = 0.89).The RAP/PAWP ratio can reflect the degree of pericardial restraint versus restrictive myocardium and was associated with the long-term survival after pericardiectomy.

Background Mitral annular calcification (MAC) is associated with worse outcomes after mitral valve replacement (MVR). With limited data available on long-term outcomes, we reviewed our experience of MVR in presence of MAC. Methods A retrospective review of 1,710 consecutive patients who underwent MVR between January 2000 and December 2015 was performed. Patients with isolated primary MVR (n = 496) were included, whereas patients with concomitant cardiac surgery (n = 1,068), previous MVR (n = 110), and mitral valve (MV) endocarditis (n = 36) were excluded. MV calcification was classified as MAC present in anterior/posterior annulus and vertically at the level of leaflets/subvalvular apparatus. A conservative approach towards annular debridement was followed. Results Our sample's mean age was 64.4 ± 14.1 years, and included 279 (56%) women. MV calcification was observed in 169 (34%) patients with MAC in 115 (23%). Older age, higher ejection fraction, peripheral vascular disease, diabetes, dialysis, and previous aortic valve surgery were associated with increased prevalence of MAC. Patients with MV calcification had higher stroke rate (p = 0.040), patients with anterior leaflet and commissural calcification had higher pacemaker implantation (p = 0.010, p = 0.001, respectively), and patients with circumferential MAC had higher postoperative dialysis (p = 0.006). Operative mortality was not significantly different (p = 0.466) between MAC (n = 1, 1%) and non-MAC (n = 9, 2%) patients. MAC was associated with late mortality (unadjusted hazard ratio, 1.62; 95% confidence interval, 1.20 to 2.18), though on multivariable analysis age, diabetes, dialysis, hypertension, previous aortic valve surgery, previous coronary artery bypass grafting, and MVR with a bioprosthetic valve were found to be independent risk factors for mortality whereas MAC was not. Conclusions A conservative approach to treat MAC achieves satisfactory results. Patients with MAC have significant comorbidities contributing to a worse survival, though MAC in itself is not a risk factor for mortality.

The Heart Team concept arose during a time when Interventional Cardiology (IC) and Cardiovascular Surgery (CVS) were grappling with and exploring competitive revascularization strategies in patient...

Renal dysfunction is frequently encountered in patients with aortic prosthesis degeneration requiring valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR). The effect of VIV TAVR on renal function in patients with bioprosthetic aortic regurgitation (AR) and stenosis (AS) is unknown.The aims of this study were to describe the change in renal function after VIV TAVR and to compare differences in renal function changes in those with predominant prosthetic regurgitation compared to stenosis.All VIV TAVR between June of 2014, and October 2019 (n = 141) at a single institution were reviewed. Baseline renal function parameters including estimated glomerular filtration rate (eGFR) were compared with post-discharge follow-up values in both prosthetic AR and AS patient groups. Linear regression analysis was performed to determine correlates of renal function change.Mean baseline eGFR was lower in the AR group (55 SD21 vs. 64 SD24 ml/min/1.73 mPatients who underwent VIV TAVR for AR experienced significant improvement of renal function at post-discharge follow-up. More advanced renal dysfunction at baseline was associated with greater improvement in renal function at post discharge in AR patients.

Objectives The aim of this study was to further evaluate clinical outcomes in patients with and without PCS. Background Prior cardiac surgery (PCS) is associated with increased surgical risk and post-operative complications following surgical aortic valve replacement (SAVR), but whether this risk is similar in transcatheter aortic valve replacement (TAVR) is unclear. Methods In the PARTNER 2A (Placement of Aortic Transcatheter Valve) trial, 2,032 patients with severe aortic stenosis at intermediate surgical risk were randomized to TAVR with the SAPIEN XT valve or SAVR. Adverse clinical outcomes at 30 days and 2 years were compared using Kaplan-Meier event rates and multivariate Cox proportional hazards regression models. The primary endpoint of the PARTNER 2 trial was all-cause death and disabling stroke. Results Five hundred nine patients (25.1%) had PCS, mostly (98.2%) coronary artery bypass grafting. There were no significant differences between TAVR and SAVR in patients with or without PCS in the rates of the primary endpoint at 30 days or 2 years. Nevertheless, an interaction was observed between PCS and treatment arm; whereas no-PCS patients treated with TAVR had higher rates of 30-day major vascular complications than patients treated with SAVR (adjusted hazard ratio: 2.66; 95% confidence interval: 1.68 to 4.22), the opposite was true for patients with PCS (adjusted hazard ratio: 0.27; 95% confidence interval: 0.11 to 0.66) (pinteraction Conclusions In the PARTNER 2A trial of intermediate-risk patients with severe aortic stenosis undergoing SAVR versus TAVR, the relative risk for 2-year adverse clinical outcomes was similar between TAVR and SAVR in patients with or without PCS.

Objectives The aim of this study was to evaluate whether transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve (S3-TAVR) results in improved quality of life (QoL) compared with previous-generation TAVR devices or surgical aortic valve replacement (SAVR). Background In patients with severe aortic stenosis at intermediate surgical risk, TAVR using the SAPIEN XT valve (XT-TAVR) results in similar QoL compared with SAVR. Compared with SAPIEN XT, the SAPIEN 3 valve offers a lower delivery profile and modifications to reduce paravalvular regurgitation. Methods Between February and December 2014, 1,078 patients at intermediate surgical risk with severe aortic stenosis were treated with S3-TAVR in the PARTNER S3i (Placement of Aortic Transcatheter Valve) trial. QoL was assessed at baseline, 1 month, and 1 year using the Kansas City Cardiomyopathy Questionnaire, Medical Outcomes Study Short Form-36, and EQ-5D. QoL outcomes of S3-TAVR patients were compared with those in the SAVR and XT-TAVR arms of the PARTNER 2A trial using propensity score stratification to adjust for differences between the treatment groups. Results Over 1 year, S3-TAVR was associated with substantial improvements in QoL compared with baseline. At 1 month, S3-TAVR was associated with better QoL than either SAVR or XT-TAVR (adjusted differences in Kansas City Cardiomyopathy Questionnaire overall summary score 15.6 and 3.7 points, respectively; p Conclusions Among patients at intermediate surgical risk with severe aortic stenosis, S3-TAVR resulted in improved QoL at both 1 month and 1 year compared with both XT-TAVR and SAVR.

Patients with active aortitis who undergo repair of ascending aortic aneurysms have an increased risk of late reoperation and decreased late survival. We aimed to determine the reasons for these poor outcomes and the influence of medical management.We reviewed records of 186 patients (median age 73.9 years; 120 women) with noninfectious aortitis after elective ascending aortic aneurysm repair (January 1955 through December 2012). Landmark analysis was used to compare outcomes in patients with isolated aortitis versus with systemic sequelae of aortitis along with outcomes of treatment with glucocorticoids.At 15 years, the overall mortality was 88.3%; at 10 years, the overall reoperation rate was 28.2%. Long-term mortality increased with older age at surgery (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.25 to 2.11, p0.001), coronary artery disease (HR 1.94, 95% CI: 1.25 to 3.01, p = 0.003), peripheral vascular disease (HR 1.79, 95% CI: 1.09 to 2.94, p = 0.02), and preoperative suspicion of aortitis (HR 4.90, 95% CI: 1.96 to 12.26, p0.001). Increased reoperation rate was associated with coronary artery disease (HR 2.69, 95% CI: 1.17 to 6.17, p = 0.02) and peripheral vascular disease (HR 3.92, 95% CI: 1.71 to 8.94, p = 0.001). Among patients free of reoperation at 6 months, systemic sequelae of aortitis were found to be significant, with an unadjusted hazard ratio of 3.59 (95% CI: 1.40 to 9.18, p = 0.008). Treatment with glucocorticoids was not associated with subsequent mortality or reoperation.The development of systemic illness secondary to aortitis was associated with increased risk of late aortic reoperations. However, glucocorticoid treatment of noninfectious aortitis did not clearly influence survival or need for reoperation.

Background The Placement of Aortic Transcatheter Valves 2A (PARTNER-2A) randomized trial compared outcomes of transfemoral transcatheter and surgical aortic valve replacement (SAVR) in intermediate-risk patients with severe aortic stenosis. The purpose of the present study was to perform an in-depth analysis of outcomes after SAVR in the PARTNER-2A trial. Methods From January 2012 to January 2014, 937 patients underwent SAVR at 57 centers. Mean age was 82 ± 6.7 years and 55% were men. Less-invasive operations were performed in 140 patients (15%) and concomitant procedures in 198 patients (21%). Major outcomes and echocardiograms were adjudicated by an independent events committee. Follow-up was 94% complete to 2 years. Results Operative mortality was 4.1% (n = 38, Society of Thoracic Surgeons predicted risk of mortality: 5.2% ± 2.3%), observed to expected ratio (O/E) was 0.8, and in-hospital stroke was 5.4% (n = 51), twice expected. Aortic clamp and bypass times were 75 ± 30 minutes and 104 ± 46 minutes, respectively. Patients having severe prosthesis–patient mismatch (n = 260, 33%) had similar survival to patients without ( p > 0.9), as did patients undergoing less-invasive SAVR ( p = 0.3). Risk factors for death included cachexia ( p = 0.004), tricuspid regurgitation ( p = 0.01), coronary artery disease ( p = 0.02), preoperative atrial fibrillation ( p = 0.001), higher white blood cell count ( p p = 0.0002). Conclusions In this adjudicated prospective study, SAVR in intermediate-risk patients had excellent results at 2 years. However, there were more in-hospital strokes than expected, most likely attributable to mandatory neurologic assessment after the procedure. No pronounced structural valve deterioration was found during 2-year follow-up. Continued long-term surveillance remains important.

We report the spectrum of aortic involvement in patients with giant cell arteritis (GCA) following review of medical records of 4,006 patients including those with imaging studies. A total of 1,450 patients (36%) had a confirmed diagnosis of GCA. Of these, 974 had aortic imaging. Of the 974 patients with imaging, 435 (45%) had an identified aortopathy. The most common aortopathy was aneurysm/dilation (69%). Overall, an annual aneurysmal growth rate of 1.5 mm/y was calculated. In patients with aneurysm/dilation, aortic dissection occurred in 18 patients (6%), and these patients had a significantly higher aneurysmal growth rate compared with those without dissection (4.5 vs 1.4 mm/y, p = 0.005). The median size of the aorta at the time of dissection was 51 mm, with 7 (39%) occurring with a maximal aortic aneurysm/dilation

Pericardiectomy is a potentially curative treatment for constrictive pericarditis. We use a median sternotomy and believe that adequate resection involves removal of the diaphragmatic pericardium and the anterior pericardium. Late outcomes depend on severity of right-sided heart failure preoperatively, the etiology of constrictive pericarditis, and adequate pericardial resection. Late results are excellent in patients with idiopathic disease or those with pericarditis secondary to prior cardiac operations. However, survival is reduced in those with radiation-induced constrictive pericarditis, primarily owing to additional secondary effects of radiation on cardiac valves, epicardial coronary arteries, and ventricular myocardium where fibrosis may cause associated restrictive cardiomyopathy.

Objective There are limited data on transcatheter aortic valve insertion after previous mitral valve operation. To better understand the associated procedural risks, we reviewed our single-center experience. Methods We retrospectively reviewed the records of 772 consecutive patients who received transcatheter aortic valve insertion from November 2008 through August 2016. There were 18 (2%) patients who had previous mitral valve operation that included valve repair in 4 patients (22%) and replacement in 14 (78%). Results Baseline characteristics included age of 77 years (interquartile range 68, 84), female sex in 11 patients (61%), New York Heart Association functional class III/IV in 14 (78%), and Society of Thoracic Surgeons predicted risk of mortality of 7.0% (5.3, 12.0). Access was transfemoral in 14 patients (78%). Valve insertion was successful in all patients and involved a balloon expandable device in 10 (56%). No patient experienced acute mitral valve dysfunction or procedure-related mortality. Follow-up echocardiography demonstrated mean systolic aortic valve gradient of 9 mm Hg (8, 12), no grade moderate or greater aortic paravalvular regurgitation, and stable mitral valve function. Kaplan-Meier estimated survival was 90.9% ± 9.1% at 1 year. Conclusions Transcatheter aortic valve insertion appears to be a safe and effective operation after previous mitral valve operation. Procedure success was achieved with both balloon expandable and self-expanding devices and was independent of arterial access method. Transcatheter valve insertion should not be denied strictly on the basis of a previous mitral valve operation.

Owing to an inevitable degeneration of grafts over time, patients may require consideration for repeat coronary artery bypass graft (CABG) surgery. As our understanding of preoperative risks associated with redo CABG surgery is limited and availability of data is limited to historical cohorts, we sought to evaluate our contemporary 20-year experience with this challenging patient population.Between January 1993 and June 2014, 748 patients underwent redo CABG surgery at our institution. Median age at reoperation was 69 years (range, 36 to 88), and 644 (86%) were male. Median follow-up was 15.1 years and was 100% complete. Preoperatively, 191 patients (26%) had diabetes mellitus, 562 (75%) had hypertension, 206 (28%) had peripheral vascular disease with 121 (16%) having a history of cerebrovascular disease, and 459 (61%) had prior myocardial infarction. Number of prior CABG operations was 1 in 682 patients (91%), 2 in 62 patients (8%), and 3 in 4 patients (1%).All patients underwent isolated redo CABG surgery; all 748 (100%) procedures were performed using cardiopulmonary bypass, with median time on pump of 95 minutes (maximum, 378) and cross-clamp time of 48 minutes (maximum, 176). There were 47 early deaths (6%); early nonfatal morbidity included renal failure in 51 patients (7%), stroke in 15 (2%), and pneumonia in 22 (3%). Overall 1-, 5-, and 10-year survival was 89%, 77%, and 51%, respectively. Age (hazard ratio [HR] 1.74, p 0.001), diabetes (HR 1.51, p0.001), peripheral vascular disease (HR 1.51, p0.001), and end-stage renal disease with dialysis (HR 11.85, p0.001) were associated with increased long-term mortality, whereas higher left ventricular ejection fraction (per 10% increase) was protective (HR 0.78, p0.001).Redo CABG can be performed safely with low early and late morbidity and mortality. Important predictors of long-term mortality such as age, diabetes, renal disease, and peripheral vascular disease were identified and should guide the treatment strategy chosen for this challenging group of patients.

Background Historically the most common causes of pericarditis necessitating pericardiectomy are infection, radiation, idiopathic causes, and inflammation. More recently, there has been a rise in iatrogenic pericardial constriction, with most cases occurring after coronary artery bypass grafting (CABG). To date, there has been no large series evaluating the incidence, presentation, and effectiveness of surgical intervention. We review our 20-year experience managing this special subset of patients. Methods From January 1993 to December 2013, 938 patients underwent pericardiectomy at our institution. We identified 98 patients who underwent pericardiectomy after previous coronary bypass grafting. Demographic information was collected along with the indication for the procedure, technical aspects of the operation, early and late morbidity and mortality, and long-term New York Heart Association (NYHA) functional class. Median age at operation was 68 years (range, 38–81 years), and 91 of the patients (93%) were men. The indication for pericardiectomy was pericardial constriction in all patients. Median preoperative left ventricular ejection fraction was 60% (range, 30%–71%) and median NYHA functional class was III (91% were class III/IV). Results The surgical approach was median sternotomy in 81 patients (83%), left thoracotomy in 16 patients (16%), and a clamshell approach in 1 patient (1%). The extent of pericardial resection was radical in 61 patients (62%), subtotal in 27 patients (28%), and completion in 10 patients (10%). Cardiopulmonary bypass was used in 63 patients (64%) and aortic cross-clamping was used in 5 patients (5%). Concomitant coronary bypass grafting was performed in 10 patients (10%). Early mortality was seen in 3 of 98 patients (3%). The median duration of late follow-up was 3.2 years (maximum, 17.5 years), and overall 5- and 10-year survival was 62% and 41%, respectively. There were no multivariate predictors of worse outcome. The sole univariate predictor of lower overall survival was the use of cardiopulmonary bypass (hazard ratio, 1.96; 95% confidence interval, 1.03–3.7]; p = 0.04). NYHA functional class was I/II in 84% of patients at a median follow-up of 3.2 years. Conclusions The rate of early mortality for pericardiectomy after previous coronary bypass grafting is low, and the late adverse impact of cardiopulmonary bypass likely reflects increased severity of disease and technical complexity. Importantly, during late follow-up extending more than 17 years, the vast majority of patients demonstrated significant improvement in NYHA functional class.

Aortic dissection is a rare but life-threatening complication of transcatheter aortic valve insertion. This paper presents the novel operative management of acute ascending aortic dissection during transcatheter valve insertion.