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Aortic valve replacement (AVR) is common in the setting of type A aortic dissection (TAAD) repair. Here, we evaluated the association between prosthesis choice and patient outcomes in an international patient cohort. We reviewed data from the International Registry of Acute Aortic Dissection (IRAD) interventional cohort to examine the relationship between valve choice and short- and mid-term patient outcomes. Between January 1996 and March 2016, 1290 surgically treated patients with TAAD were entered into the IRAD interventional cohort. Of those, 364 patients undergoing TAAD repair underwent aortic valve replacement (AVR; mean age, 57 years). The mechanical valve cohort consisted of 189 patients, of which 151 (79.9%) had a root replacement. The nonmechanical valve cohort consisted of 5 patients who received homografts and 160 patients who received a biologic AVR, with a total of 118 (71.5%) patients who underwent root replacements. The mean follow-up time was 2.92 ± 1.75 years overall (2.46 ± 1.69 years for the mechanical valve cohort and 3.48 ± 1.8 years for the nonmechanical valve cohort). After propensity matching, Kaplan-Meier estimates of 4-year survival rates after surgery were 64.8% in the mechanical valve group compared with 74.7% in the nonmechanical valve group (p = 0.921). A stratified Cox model for 4-year mortality showed no difference in hazard between valve types after adjusting for the propensity score (p = 0.854). A biologic valve is a reasonable option in patients with TAAD who require AVR. Although this option avoids the potential risks of anticoagulation, long-term follow up is necessary to assess the effect of reoperations or transcatheter interventions for structural valve degeneration.

Background Learning curves and skill attrition with aging have been reported to impair outcomes in select surgical subspecialties, but their role in complex cardiac surgery remains unknown. Methods From 1986 to 2019, 2314 patients underwent reoperative cardiac surgery: coronary artery bypass grafting (n = 543), valve (n = 1527), or combined coronary artery bypass grafting and valve (n = 244). Thirty-four different surgeons in practice between 1 and 39 years were included. Standardized mortality ratio (observed-to-expected) was determined for all surgeons in each post-training year of experience. Results Risk-adjusted cumulative sum change-point analysis was used to define five distinct career phases: 0 to 4 years, 5 to 8 years, 9 to 17 years, 18 to 28 years, and 29 to 39 years. With 5 to 8 years and 18 to 28 years of experience, standardized mortality ratio was near unity (0.95 and 1.05, respectively) and lowest with 9 to 17 years of experience (0.78, P = .03). In the youngest experience group (0 to 4 years), observed and expected mortality were both highest, and standardized mortality ratio was elevated at 1.29, which approached statistical significance (P = .059). In the oldest experience group (29 to 39 years), expected mortality was low compared with most other groups but observed mortality increased, yielding a significantly elevated standardized mortality ratio at 1.53 (P = .032). Conclusions Standardized mortality ratios with reoperative cardiac surgery were highest early and late in a surgeon’s career and lowest in mid career. As surgeons gain experience, outcomes improve through the first two career decades, then stabilize in the third decade before declining in the fourth decade.

Aortic valve replacement is recommended in symptomatic patients with severe aortic stenosis (AS) or asymptomatic with reduced left ventricular ejection fraction (LVEF). The treatment algorithm of p...

In patients with end-stage renal disease (ESRD), surgical aortic valve replacement is associated with higher early and late mortality, and adverse outcomes compared with patients without renal disease. Transcatheter aortic valve replacement (TAVR) offers another alternative, but there are limited reported outcomes.The purpose of this study was to determine the outcomes of TAVR in patients with ESRD.Among the first 72,631 patients with severe aortic stenosis (AS) treated with TAVR enrolled in the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) TVT (Transcatheter Valve Therapies) registry, 3,053 (4.2%) patients had ESRD and were compared with patients who were not on dialysis for demographics, risk factors, and outcomes.Compared with the nondialysis patients, ESRD patients were younger (76 years vs. 83 years; p 0.01) and had higher rates of comorbidities leading to a higher STS predicted risk of mortality (median 13.5% vs. 6.2%; p 0.01). ESRD patients had a higher in-hospital mortality (5.1% vs. 3.4%; p 0.01), although the observed to expected ratio was lower (0.32 vs. 0.44; p 0.01). ESRD patients also had a similar rate of major vascular complications (4.5% vs. 4.6%; p = 0.86), but a higher rate of major bleeding (1.4% vs. 1.0%; p = 0.03). The 1-year mortality was significantly higher in dialysis patients (36.8% vs. 18.7%; p 0.01).Patients undergoing TAVR with ESRD are at higher risk and had higher in-hospital mortality and bleeding, but similar vascular complications, when compared with those who are not dialysis dependent. The 1-year survival raises concerns regarding diminished benefit in this population. TAVR should be used judiciously after full discussion of the risk-benefit ratio in patients on dialysis.

The development of transcatheter interventions to provide a minimally invasive alternative to open surgical repair has revolutionized the care of patients with valvular heart disease. Recently, this technology has been expanded to allow for the treatment of pathology of the mitral valve. This review discusses the anesthetic considerations for patients presenting for transcatheter management of mitral valve disease, including transcatheter mitral valve replacement (TMVR) and transcatheter mitral valve repair (TMVRep). The initial focus is on the current literature on transcatheter interventions for mitral valve pathologies as well as current and developing technology for TMVR and TMVRep. The authors' institutional experience with anesthetic management for the TMVR and TMVRep procedures is described, including potential pitfalls and complications, concluding with a discussion of the role of transesophageal echocardiography in the care of this patient population.

Objective Obesity is a strong and independent factor for the development of atrial fibrillation (AF), and adversely impacts the success of catheter ablation procedures for AF. This study evaluated the impact of body mass index (BMI) on the outcomes following surgical ablation of AF. Methods Between 2003 and 2019, 236 patients underwent a stand-alone biatrial Cox maze IV procedure (CMP-IV) for refractory AF. Obesity was defined as BMI ≥30 kg/m2. Patients were divided into two groups: BMI 2 ( n = 100) and BMI ≥30 kg/m2 ( n = 136). Freedom from atrial tachyarrhythmia (ATA) was determined using electrocardiography, Holter, or pacemaker interrogation at 1 year and annually thereafter. Recurrence was defined as any documented ATA lasting ≥30 s. Predictors of recurrence were determined using multivariable logistic regression. Preoperative and procedural outcomes were compared between groups. Results Obese patients had a higher rate of diabetes (16% vs 7%, P = 0.044) and larger left atrial diameter (4.9 ± 1.1 cm vs 4.6 ± 1.0 cm, P = 0.021) when compared to non-obese patients. There was no difference in major complication rate between the groups (4% vs 7%, P = 0.389). There was no operative mortality in either group. During 4.1 ± 2.4 years of follow-up, there was no significant difference in freedom from ATA with or without antiarrhythmic drugs in obese patients when compared to the non-obese group ( P > 0.05). Absence of sinus rhythm at discharge predicted AF recurrence up to 7 years postoperatively. Conclusions As opposed to catheter ablation, obesity did not adversely impact the short and long-term outcomes of stand-alone surgical ablation with CMP-IV, and BMI was not a predictor of AF recurrence. Additionally, there was no significant increase in major complications in obese patients.

INTRODUCTION: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and results in significant morbidity and mortality. The Cox-Maze IV procedure (CMP-IV) has been shown to have excellent efficacy in returning patients to sinus rhythm, but there have been few reports of late follow-up in sizable cohorts of patients with longstanding persistent AF, the most difficult type of AF to treat. METHODS AND RESULTS: Between May 2003 and March 2020, 174 consecutive patients underwent a stand-alone CMP-IV for longstanding persistent AF. Rhythm outcome was assessed postoperatively for up to 10 years, primarily via prolonged monitoring (Holter monitor, pacemaker interrogation, or implantable loop recorder). Fine-Gray regression was used to investigate factors associated with atrial tachyarrhythmia (ATA) recurrence, with death as a competing risk. Median duration of preoperative AF was 7.8 years (interquartile range: 4.0–12.0 years), with 71% (124/174) having failed at least one prior catheter-based ablation. There were no 30-day mortalities. Freedom from ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7 years, respectively. On regression analysis, preoperative AF duration and early postoperative ATAs were associated with late ATAs recurrence. CONCLUSION: Despite the majority of patients having a long-duration of preoperative AF and having failed at least one catheter-based ablation, the stand-alone CMP-IV had excellent late efficacy in patients with longstanding persistent AF, with low morbidity and no mortality. We recommend consideration of stand-alone CMP-IV for patients with longstanding persistent AF who have failed or are poor candidates for catheter ablation.

Objectives Stand-alone surgical ablation of atrial fibrillation is indicated in patients with refractory atrial fibrillation who have failed medical or catheter-based ablation. Few reports of late outcomes after stand-alone surgical ablation exist using comprehensive follow-up with strict definitions of success. This study examined our late outcomes of the stand-alone Cox-Maze IV procedure. Methods Between January 2003 and December 2019, 236 patients underwent a stand-alone Cox-Maze IV for refractory atrial fibrillation. Freedom from atrial tachyarrhythmias was assessed by electrocardiography, Holter, or pacemaker interrogation for up to 10 years, with a mean follow-up of 4.8 ± 3.5 years. Rhythm outcomes were compared in multiple subgroups. Factors associated with recurrence were determined using Fine-Gray regression, allowing for death as the competing risk. Results The majority of patients (176/236, 75%) had nonparoxysmal atrial fibrillation. Median duration of preoperative atrial fibrillation was 6.2 years (interquartile range, 3-11). Fifty-nine percent of patients (140/236) failed 1 or more prior catheter-based ablation. Thirteen patients (6%) experienced a major complication. There was no 30-day mortality. Freedom from atrial tachyarrhythmias was 94% (187/199), 89% (81/91), and 77% (24/31) at 1, 5, and 10 years, respectively. There was no difference in freedom from atrial tachyarrhythmias between patients with paroxysmal atrial fibrillation versus nonparoxysmal atrial fibrillation (P > .05) or those undergoing sternotomy versus a minimally invasive approach (P > .05). Increased left atrial size and number of catheter ablations were associated with late atrial fibrillation recurrence. For patients who experienced any atrial tachyarrhythmia recurrence, the median number of recurrences was 1.5 (1.0-3.0). Conclusions The stand-alone Cox-Maze IV had excellent late efficacy at maintaining sinus rhythm in patients with symptomatic, refractory atrial fibrillation, with low morbidity and no mortality. The Cox-Maze IV, in contrast to catheter-based ablation, was equally effective in patients with paroxysmal and nonparoxysmal atrial fibrillation.

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.

Objective Atrial fibrillation (AF) is associated with an increased mortality risk. The Cox-maze IV procedure (CM4) performed concomitantly with other cardiac procedures has been shown to be effective for restoring sinus rhythm. However, few data have been published on the late survival of patients undergoing a concomitant CM4. Methods Patients undergoing cardiac surgery were retrospectively reviewed from 2001 to 2016 (n = 10,859). Patients were stratified into 3 groups: patients with a history of AF receiving a concomitant CM4 (CM4; n = 438), patients with a history of AF unaddressed during surgery (Untreated AF; n = 1510), and patients without AF history (No AF; n = 8911). Propensity score matching was conducted between the CM4 and Untreated AF groups, and between the CM4 and No AF groups. Results Thirty-day mortality was similar between the matched groups. Kaplan-Meier analysis showed greater survival for CM4 compared to Untreated AF ( P = .004). Ten-year survival was 62% for CM4 and 42% for Untreated AF. Adjusted hazard ratio was 0.47 (95% confidence interval, 0.26-0.86, P = .014). No difference in survival was found between CM4 and No AF groups with the Kaplan–Meier analysis ( P = .847). Ten-year survival was 63% for CM4 and 55% for No AF. Adjusted hazard ratio was 1.03 (95% confidence interval, 0.51-2.11, P = .929). Conclusions For selected patients with a history of AF undergoing cardiac surgery, concomitant CM4 did not add significantly to postoperative morbidity or mortality and was associated with improved late survival compared with patients with untreated AF and a similar survival to patients without a history of AF.

The incidence of atrial fibrillation (AF) in patients older than 75 years of age is expected to increase, and its treatment remains challenging. This study evaluated the impact of age on the outcomes of surgical ablation of AF.A retrospective review was performed of patients who underwent the Cox-maze IV procedure at a single institution between 2005 and 2017. The patients were divided into a younger (age75 years, n = 548) and an elderly cohort (age ≥75 years, n = 148). Rhythm outcomes were assessed at 1 year and annually thereafter. Predictors of first atrial tachyarrhythmia (ATA) recurrence were determined using Fine-Gray regression, allowing for death as the competing risk.The mean age of the elderly group was 78.5 ± 2.8 years. The majority of patients (423/696, 61%) had nonparoxysmal AF. The elderly patients had a lower body mass index (P .001) and greater rates of hypertension (P = .011), previous myocardial infarction (P = .017), heart failure (P .001), and preoperative pacemaker (P = .008). Postoperatively, the elderly group had a greater rate of overall major complications (23% vs 14%, P = .017) and 30-day mortality (6% vs 2%, P = .026). The percent freedom from ATAs and antiarrhythmic drugs was lower in the elderly patients at 3 (69% vs 82%, P = .030) and 4 years (65% vs 79%, P = .043). By competing risk analysis, the incidence of first ATA recurrence was greater in elderly patients (33% vs 20% at 5 years; Gray test, P = .005). On Fine-Gray regression adjusted for clinically relevant covariates, increasing age was identified as a predictor of ATAs recurrence (subdistribution hazard ratio, 1.03; 95% confidence interval, 1.02-1.05, P .001).The efficacy of the Cox-maze IV procedure was worse in elderly patients; however, the majority of patients remained free of ATAs at 5 years. The lower success rate in these greater-risk patients should be considered when deciding to perform surgical ablation.

Brief Summary Prosthesis-patient mismatch is prevalent during both surgical aortic valve replacement and transcatheter aortic valve replacement, and severe PPM associated with poor long-term survival.

Objective To determine whether the etiology of mitral valve disease (MVD), due to either rheumatic or degenerative pathology, influences long-term outcomes after the Cox-Maze IV procedure (CMPIV). Methods Between February 2001 and July 2015, 245 patients received a CMIV and concomitant mitral valve procedure. Patients were separated into 2 cohorts based on their etiology of MVD, degenerative (n = 153) and rheumatic (n = 92). Patients were followed prospectively (mean follow-up: 41 ± 37 months) for recurrent atrial tachyarrhythmias (ATAs). Perioperative variables and long-term freedom from ATAs on and off antiarrhythmic drugs (AADs) were analyzed retrospectively. Results The 2 groups differed in that patients with rheumatic MVD were younger, more likely female, had a larger preoperative left atrial diameter, a longer duration of atrial fibrillation (AF), a greater percentage of longstanding persistent AF, and worse New York Heart Association functional class ( P ≤ .001). Although there was no difference in operative mortality or overall major complications between the groups, the median length of stay in the intensive care unit was longer in the rheumatic cohort. Freedom from recurrent ATAs through 5 years was similar between the 2 cohorts. Predictors of recurrence included failure to use a box-lesion ( P = .012), the duration of preoperative AF ( P = .001), and early occurrence of ATAs ( P = .015). Conclusions The long-term efficacy of the CMPIV in restoring sinus rhythm was similar in patients with either rheumatic or degenerative mitral valve disease. Despite representing a sicker patient population with a longer duration of preoperative AF, patients with rheumatic MVD equally benefit from the CMPIV.

Objective The Cox-Maze IV procedure has been shown to be an effective treatment for atrial fibrillation when performed concomitantly with other operations either via median sternotomy or right minithoracotomy. Few studies have compared these approaches in patients with lone atrial fibrillation. This study examined outcomes with sternotomy versus minithoracotomy in stand-alone Cox-Maze IV procedures at our institution. Methods Between 2002 and 2015, 195 patients underwent stand-alone biatrial Cox-Maze IV. Minithoracotomy was used in 75 patients, sternotomy in 120. Freedom from atrial tachyarrhythmias was ascertained using electrocardiography, Holter, or pacemaker interrogation at 3 to 60 months. Predictors of recurrence were determined using logistic regression. Results Of 23 preoperative variables, the only differences between groups were that minithoracotomy patients had a higher rate of New York Heart Association 3/4 symptoms and a lower rate of previous stroke. Minithoracotomy and sternotomy patients had similar atrial fibrillation duration and type. Minithoracotomy patients had a smaller left atrial diameter (4.5 vs 4.8 cm, P = 0.03). More minithoracotomy patients received a box lesion (73/75 vs 100/120, P = 0.002). Minithoracotomy patients had a shorter hospital stay (7 vs 8 days, P = 0.009) and a similar rate of major complications (3/75 (4%) vs 7/120 (6%), P = 0.74). There were no differences in mortality or freedom from atrial tachyarrhythmias. Predictors of atrial fibrillation recurrence included a preoperative pacemaker, omission of the left atrial roof line, and New York Heart Association 3/4 symptoms. Conclusions Stand-alone Cox-Maze IV via minithoracotomy was as effective as via sternotomy with a shorter hospital stay. A minimally invasive approach is our procedure of choice.

Objective Most patients with atrial fibrillation (AF) undergoing cardiac surgery do not receive concomitant ablation. This study reviewed outcomes of patients with AF undergoing Cox-maze IV (CMIV) procedure with radiofrequency and cryoablation and coronary artery bypass grafting (CABG) at our institution. Methods Between the introduction of radiofrequency ablation in 2002 and 2015, 135 patients underwent left- or biatrial CMIV with CABG. Patients undergoing other cardiac procedures, except mitral valve repair, or who had emergent, reoperative, or off-pump procedures were excluded. Eighty-three patients remained in the study group after exclusion criteria were applied. Freedom from atrial tachyarrhythmias (ATAs) was ascertained using electrocardiogram, Holter monitor, or pacemaker interrogation at 1 to 5 years postoperatively. Results Operative mortality was 3%. Freedom from ATAs at 1 year in the CMIV group was 98%, with 88% off antiarrhythmia drugs. Freedom from ATAs and antiarrhythmia drugs was 70% at 5 years. Conclusions The addition of CMIV to CABG resulted in excellent freedom from ATAs at 1 to 5 years. These patients are at increased risk for nonfatal complications compared with others undergoing concomitant surgical ablation.

Background At a Midwestern academic medical center, we introduced a structured teamwork training program to cardiothoracic operating room members with a goal of greater than or equal to 90% reporting positive psychological safety after the program. Methods We conducted teamwork training over 3 months. We distributed confidential questionnaires before the training, and then at 6 months and 12 months after the training. The primary outcome was the percentage of respondents reporting good or excellent psychological safety. Surveys were also distributed at the end of each case. Secondary outcomes were medical errors reported. Comparisons between percentages were evaluated with chi-square test. We examined the turnover of nurses and surgical technologists. Results Positive psychological safety was reported by 57 of 73 (78.1%) at baseline and by 60 of 68 (88.2%) at 12 months (difference = 10.1%; 95% confidence interval, -2.4% to 23.4%; P = .122). On the daily survey, 93.9% (n = 2786 of 2987) of operating room team members strongly agreed with the statement “I felt comfortable speaking up with questions and concerns” during the last quarter of the study. Reported medical errors decreased from 7.44% (n = 78 of 1048) in the first 6 months of the study to 4.65% (n = 55 of 1184) in the second 6 months (difference = 2.79%; 95% confidence interval, 0.8% to 4.8%; P = .005). In 2015, 19 nurses of a pool of 40 (47.5%) left, followed by 7 (17.5%) in 2016 and 10 (25%) in 2017. Conclusions Overall, the results of this study suggest that structured teamwork training in the cardiothoracic operating room environment has the potential to improve teamwork, psychological safety, and communication, and potentially also patient outcomes.

Completeness of revascularization is important for patients undergoing coronary artery bypass graft surgery, but information on its long-term impact in octogenarian patients is lacking.From 1986 to 2004, 525 consecutive patients aged 80 years or more (mean age 82 ± 3 years) underwent coronary artery bypass graft surgery and were followed for a minimum of 10 years or until death. Outcome was stratified based on extent of revascularization, defined as total (graft to every diseased vessel), complete (graft to each region but not every diseased vessel), or incomplete (bypass not done to all suitable regions or vessels).Follow-up of 3,155 patient-years (mean follow-up 73 ± 54 months) was 99% complete. Overall operative mortality was 8% (41 of 525), and was lower for elective than for urgent/emergent cases (4.2% versus 16% ± 6%, p 0.001, respectively). There was a trend toward higher operative mortality with incomplete (13% ± 6%) versus complete (8% ± 4%) or total revascularization (6% ± 3%; p = 0.09). For operative survivors, mean survival was significantly improved with total and complete revascularization (6.9 and 6.8 years, respectively), compared with incomplete revascularization (5.4 years, p0.008). For total, complete, and incomplete revascularization, survival at 5 years was 61% ± 3%, 61% ± 4%, and 47% ± 5%, respectively. Ten-year survival was 27% ± 3%, 21% ± 3%, and 16% ± 4% (p = 0.01), respectively, in these groups.Incomplete revascularization in octogenarians is associated with decreased long-term survival when compared with total or complete revascularization. There was no survival benefit with total over complete revascularization. Octogenarians can have good long-term survival, especially with adequate revascularization.

Background Current guidelines recommend at least 24-hour Holter monitoring at 6-month intervals to evaluate the recurrence of atrial fibrillation (AF) after surgical ablation. In this prospective multicenter study, conventional intermittent methods of AF monitoring were compared with continuous monitoring using an implantable loop recorder (ILR). Methods From August 2011 to January 2014, 47 patients receiving surgical treatment for AF at 2 institutions had an ILR placed at the time of operation. Each atrial tachyarrhythmia (ATA) of 2 minutes or more was saved. Patients transmitted ILR recordings bimonthly or after any symptomatic event. Up to 27 minutes of data was stored before files were overwritten. Patients also underwent electrocardiography (ECG) and 24-hour Holter monitoring at 3, 6, and 12 months. ILR compliance was defined as any transmission between 0 and 3 months, 3 and 6 months, or 6 and 12 months. Freedom from ATAs was calculated and compared. Results ILR compliance at 12 months was 93% compared with ECG and Holter monitoring compliance of 85% and 76%, respectively. ILR devices reported a total of 20,878 ATAs. Of these, 11% of episodes were available for review and 46% were confirmed as AF. Freedom from ATAs was no different between continuous and intermittent monitoring at 1 year. Symptomatic events accounted for 187 episodes; however, only 10% were confirmed as AF. Conclusions ILR was equivalent at detecting ATAs when compared with Holter monitoring or ECG. However, the high rate of false-positive readings and the limited number of events available for review present barriers to broad implementation of this form of monitoring. Very few symptomatic events were AF on review.

Objective Approximately 50% of patients with severe symptomatic mitral regurgitation are deemed too high risk for surgery. The MitraClip procedure is a viable option for this population. Our goal was to assess outcomes and survival of patients who underwent the MitraClip procedure at an institution where mitral valve surgery is routinely performed. Methods A retrospective study of patients undergoing the MitraClip procedure was performed. Baseline characteristics, perioperative outcomes, and follow-up echocardiographic and clinical outcomes were examined. Primary end point was survival. Secondary end points included technical failure (residual 3/4+ mitral regurgitation), reoperation, New York Heart Association symptoms, 30-day mortality, and other clinical outcomes. Predictors of mortality were determined using multivariable regression analysis. Results Fifty consecutive patients underwent the MitraClip procedure during the 4-year period. The average age was 83, the Society of Thoracic Surgeons predicted risk of mortality mean was 9.4%, 88% (44/50) had New York Heart Association III/IV symptoms, 86% (43/50) had 4+ mitral regurgitation, and 72% (36/50) had degenerative mitral disease etiology. Echocardiographic data (median [interquartile range] follow-up = 43 [26–392]) showed that 86% (43/50) of patients had 2+ or less mitral regurgitation. Sixty percent (24/40) had New York Heart Association I/II symptoms at last follow-up. Predictors of mortality were higher Society of Thoracic Surgeons predicted risk of mortality ( P = 0.042, hazard ratio = 1.098) and previous cardiac surgery ( P = 0.013, hazard ratio = 3.848). Survival at 1 and 2 years was 75% and 63%, respectively. Conclusions Many patients with mitral valve regurgitation who are high risk for open surgery can be treated with the MitraClip procedure. In our study, most patients (86%) had a technically successful operation and postoperative outcomes including survival were acceptable.

Transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve replacement expose operators to radiation. These procedures differ primarily in whether they are performed via a transfemoral (TF) or an alternative access (AA) approach. This study compared operator radiation exposure during transcatheter valve implantation when performed via a TF vs an AA approach, when performed in a catheterization lab vs a hybrid operating room (OR), and investigated the potential benefit of disposable shielding.Dosimeters were worn during TAVR-TF (n = 50) and TAVR-AA (n = 31) procedures by operators. All TAVR-AA procedures were performed in a hybrid OR and TF procedures were performed in either catheterization labs (n = 16) or a hybrid OR (n = 34). Disposable radiation shielding pads (RADPAD; Worldwide Innovations and Technologies, Inc, Kansas City) or a placebo were added in a randomized, blinded fashion.Team radiation exposure was higher after TAVR-AA vs TAVR-TF (median 15.1 mRad [interquartile range: IQR 8.6, 32.4] vs 5.5 mRad [IQR 2.4, 9.8], P.001). TAVR-TF procedures required the same amount of fluoroscopy time regardless of where they were performed (20.3 ± 7.4 min in hybrid OR vs 19.0 ± 6.4 min in catheterization lab, P = .55). However, radiation exposure for TAVR-TF remained higher when performed in a hybrid OR (median 9.0 mRad [IQR 4.5, 11.9] vs 2.2 mRad [IQR 1.3, 2.8], P.001). Radiation exposure was greatest for TAVR-AA (median 15.1 mRad [IQR 8.6, 32.4]). The use of RADPAD did not decrease radiation exposure (median 9.0 mRad [IQR 4.5, 14.7] vs 9.4 mRad [IQR 2.8, 19.5], P = .82).Procedures performed in the hybrid OR were associated with higher operator radiation exposure. In comparison with the TF approach, AA cases had the highest levels of operator radiation. This is particularly important in cases of transcatheter mitral valve replacement that can only be done via an AA approach. The use of disposable radiation shielding in this series did not attenuate operator radiation exposure. Radiation shielding within hybrid ORs should be scrutinized in an effort to remain on par with that found within catheterization labs.

Aortic stenosis is the most prevalent valvular cardiovascular disease affecting the population over the age of 65 years. Transcatheter aortic valve replacement (TAVR) was developed as a minimally invasive surgical intervention to treat aortic stenosis in patients at high risk for surgical complications. Although the most commonly used approach for placement of a transcatheter aortic valve is in retrograde fashion via a transfemoral approach, narrowed luminal diameters, extensive atherosclerotic disease, or significant tortuosity may limit use of this route. In these patients, alternative methods including subclavian, transaortic, and transapical approaches should be considered. An understanding of these access routes and their respective indications and contraindications allows the radiologist to provide additional preprocedure measurements and images to help guide placement of the valve. ©RSNA, 2018.

In patients with atrial fibrillation (AF), the addition of surgical ablation to aortic valve replacement (AVR) does not increase procedural morbidity or mortality. However, efficacy in this population has not been carefully evaluated. This study compared outcomes between patients undergoing stand-alone Cox-Maze IV with those undergoing surgical ablation and concomitant AVR.From January 2002 to May 2014, 188 patients received a stand-alone Cox-Maze IV (n = 113) or surgical ablation with concomitant AVR (n = 75). In the concomitant AVR group, patients underwent Cox-Maze IV (n = 58), left-sided Cox-Maze IV (n = 3), or pulmonary vein isolation (n = 14). Thirty-one perioperative variables were compared. Freedoms from AF on and off antiarrhythmic drugs were evaluated at 3, 6, 12, and 24 months.Follow-up was available in 97% of patients. Freedom from AF on and off antiarrhythmic drugs in patients receiving a stand-alone Cox-Maze IV versus concomitant AVR was not significantly different at any time point. The concomitant AVR group had more comorbidities, paroxysmal AF, pacemaker implantations (24% vs 5%, p = 0.002), and complications (25% vs 5%, p0.001). Freedoms from AF off antiarrhythmic drugs for patients receiving an AVR and pulmonary vein isolation at 1 year was only 50%, which was significantly lower than patients receiving an AVR and Cox-Maze IV ( 94%, p = 0.001).A Cox-Maze IV with concomitant AVR is as effective as a stand-alone Cox-Maze IV in treating AF, even in an older population with more comorbidities. Pulmonary vein isolation was not as effective and is not recommended in this population. A Cox-Maze IV should be considered in all patients undergoing AVR with a history of AF.

Objectives This study sought to clarify the clinical and echocardiographic prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR). Background The clinical significance of cardiac biomarker elevation after TAVR remains unclear. Methods Patients treated with TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) trial were divided into tertiles (T1, T2, T3) based on the difference between the values on post-procedure day 1 and the baseline values of 2 cardiac biomarkers: cardiac troponin I (ΔcTnI); and creatine kinase-myocardial band (ΔCK-MB) fraction. Patients were stratified according to their access route: transfemoral (TF) (n = 1,840) or transapical (TA) (n = 1,173). Results At 30 days after TF-TAVR, patients in the highest tertile (T3) of cardiac biomarker elevation had a higher rate of all-cause mortality (ΔcTnI: T3: 5.4% vs. T1: 0.5%, p = 0.006; ΔCK-MB: T3: 5.7% vs. T1: 0.9%, p = 0.006) and cardiovascular mortality (ΔcTnI: T3: 4.9% vs. T1: 0.5%, p = 0.01; ΔCK-MB: T3: 3.9% vs. T1: 0.5%, p = 0.02). At 1 year, only patients in the highest CK-MB tertile had higher rates of all-cause (25.4% vs. 16.8%, p = 0.02) and cardiovascular (10.3% vs. 5.0%) mortality. Multivariable analysis demonstrated that greater release of cardiac biomarkers was independently associated with increased mortality in the TF population. After TA-TAVR, being in the highest tertile of cardiac biomarker elevation had no influence on clinical and echocardiographic outcomes at 30 days and 1 year. Conclusions After TF-TAVR, a greater degree of myocardial injury was associated with higher rates of 30-day all-cause and cardiovascular mortality. At 1 year, being in the highest tertile of ΔCK-MB was correlated with a higher rate of all-cause and cardiac mortality. Finally, the level of myocardial injury after TA-TAVR had no impact on clinical and echocardiographic outcomes.

Pulmonary hypertension (PH) is associated with increased mortality after surgical or transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS), and when the pulmonary artery pressure is particularly elevated, there may be questions about the clinical benefit of TAVR. We aimed to identify clinical and haemodynamic factors associated with increased mortality after TAVR among those with moderate/severe PH.Among patients with symptomatic AS at high or prohibitive surgical risk receiving TAVR in the Placement of Aortic Transcatheter Valves (PARTNER) I randomised trial or registry, 2180 patients with an invasive measurement of mean pulmonary artery pressure (mPAP) recorded were included, and moderate/severe PH was defined as an mPAP ≥35 mm Hg.Increasing severity of PH was associated with progressively worse 1-year all-cause mortality: none (n=785, 18.6%), mild (n=838, 22.7%) and moderate/severe (n=557, 25.0%) (p=0.01). The increased hazard of mortality associated with moderate/severe PH was observed in females, but not males (interaction p=0.03). In adjusted analyses, females with moderate/severe PH had an increased hazard of death at 1 year compared with females without PH (adjusted HR 2.14, 95% CI 1.44 to 3.18), whereas those with mild PH did not. Among males, there was no increased hazard of death associated with any severity of PH. In a multivariable Cox model of patients with moderate/severe PH, oxygen-dependent lung disease, inability to perform a 6 min walk, impaired renal function and lower aortic valve mean gradient were independently associated with increased 1-year mortality (p0.05 for all), whereas several haemodynamic indices were not. A risk score, including these factors, was able to identify patients with a 15% vs 59% 1-year mortality.The relationship between moderate/severe PH and increased mortality after TAVR is altered by sex, and clinical factors appear to be more influential in stratifying risk than haemodynamic indices. These findings may have implications for the evaluation of and treatment decisions for patients referred for TAVR with significant PH.NCT00530894.

An inflammatory response after cardiac surgery is associated with worse clinical outcomes, but recent trials to attenuate it have been neutral. We evaluated the association between systemic inflammatory response syndrome (SIRS) and mortality after transcatheter (TAVR) and surgical aortic valve replacement (SAVR) for aortic stenosis (AS) and evaluated whether diabetes influenced this relationship.Patients (n=747) with severe AS treated with TAVR (n=264) or SAVR (n=483) between January 2008 and December 2013 were included and 37% had diabetes mellitus. SIRS was defined by four criteria 12-48 h after aortic valve replacement (AVR): (1) white blood cell count4 or12; (2) heart rate90; (3) temperature36 or38°C; or (4) respiratory rate20. Severe SIRS was defined as meeting all four criteria. The primary endpoint was 6-month all-cause mortality (60 deaths occurred by 6 months). Inverse probability weighting (IPW) was performed on 44 baseline and procedural variables to minimise confounding.Severe SIRS developed in 6% of TAVR patients and 11% of SAVR patients (p=0.02). Six-month mortality tended to be higher in those with severe SIRS (15.5%) versus those without (7.4%) (p=0.07). After adjustment, severe SIRS was associated with higher 6-month mortality (IPW adjusted HR 2.77, 95% CI 2.04 to 3.76, p0.001). Moreover, severe SIRS was more strongly associated with increased mortality in diabetic (IPW adjusted HR 4.12, 95% CI 2.69 to 6.31, p0.001) than non-diabetic patients (IPW adjusted HR 1.74, 95% CI 1.10 to 2.73, p=0.02) (interaction p=0.007). The adverse effect of severe SIRS on mortality was similar after TAVR and SAVR.Severe SIRS was associated with a higher mortality after SAVR or TAVR. It occurred more commonly after SAVR and had a greater effect on mortality in diabetic patients. These findings may have implications for treatment decisions in patients with AS, may help explain differences in outcomes between different AVR approaches and identify diabetic patients as a high-risk subgroup to target in clinical trials with therapies to attenuate SIRS.

Objectives Surgery for type A aortic dissection is associated with a high operative mortality, and a variety of predictive risk factors have been reported. We hypothesized that a combination of risk factors associated with organ malperfusion and severe acidosis that are not currently documented in databases would be associated with a level of extreme operative risk that would warrant the consideration of treatment paradigms other than immediate ascending aortic surgery. Methods Charts of patients undergoing repair of acute type A aortic dissection between January 1, 1996, and May 1, 2016, were queried for preoperative malperfusion, preoperative base deficit, pH, bicarbonate, cardiopulmonary resuscitation, severe aortic insufficiency, redo status, and preoperative intubation. Multivariable logistic analyses were considered to evaluate interested variables and operative mortality. Results Between January 1, 1996, and May 1, 2016, 282 patients underwent surgical repair of type A aortic dissection. A total of 66 patients had a calculated base deficit −5 or greater. Eleven of 12 patients (92%) with severe acidosis (base deficit ≥−10) with malperfusion had operative mortality. No patient with severe acidosis with abdominal malperfusion survived. Multivariable analyses identified base deficit, intubation, congestive heart failure, dyslipidemia/statin use, and renal failure as predictors of operative death. The most significant predictor was base deficit −10 or greater (odds ratio, 9.602; 95% confidence interval, 2.649-34.799). Conclusions The combination of severe acidosis (base deficit ≥−10) with abdominal malperfusion was uniformly fatal. Further research is needed to determine whether the identification of extreme risk warrants consideration of alternate treatment options to address the cause of severe acidosis before ascending aortic procedures.

Background— After aortic valve replacement, left ventricular afterload is often characterized by the residual valve obstruction. Our objective was to determine whether higher systemic arterial afterload—as reflected in blood pressure, pulsatile and resistive load—is associated with adverse clinical outcomes after transcatheter aortic valve replacement (TAVR). Methods and Results— Total, pulsatile, and resistive arterial load were measured in 2141 patients with severe aortic stenosis treated with TAVR in the PARTNER I trial (Placement of Aortic Transcatheter Valve) who had systolic blood pressure (SBP) and an echocardiogram obtained 30 days after TAVR. The primary end point was 30-day to 1-year all-cause mortality. Lower SBP at 30 days after TAVR was associated with higher mortality (20.0% for SBP 100–129 mm Hg versus 12.0% for SBP 130–170 mm Hg; P P Conclusions— Even after relief of valve obstruction in patients with aortic stenosis, there is an independent association between post-TAVR blood pressure, systemic arterial load, and mortality. Blood pressure goals in patients with a history of aortic stenosis may need to be redefined. Increased pulsatile arterial load, rather than blood pressure, may be a target for adjunctive medical therapy to improve outcomes after TAVR. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894

The recently developed American College of Cardiology Foundation-Society of Thoracic Surgeons (STS) Collaboration on the Comparative Effectiveness of Revascularization Strategy (ASCERT) Long-Term Survival Probability Calculator is a valuable addition to existing short-term risk-prediction tools for cardiac surgical procedures but has yet to be externally validated.Institutional data of 654 patients aged 65 years or older undergoing isolated coronary artery bypass grafting between 2005 and 2010 were reviewed. Predicted survival probabilities were calculated using the ASCERT model. Survival data were collected using the Social Security Death Index and institutional medical records. Model calibration and discrimination were assessed for the overall sample and for risk-stratified subgroups based on (1) ASCERT 7-year survival probability and (2) the predicted risk of mortality (PROM) from the STS Short-Term Risk Calculator. Logistic regression analysis was performed to evaluate additional perioperative variables contributing to death.Overall survival was 92.1% (569 of 597) at 1 year and 50.5% (164 of 325) at 7 years. Calibration assessment found no significant differences between predicted and actual survival curves for the overall sample or for the risk-stratified subgroups, whether stratified by predicted 7-year survival or by PROM. Discriminative performance was comparable between the ASCERT and PROM models for 7-year survival prediction (p0.001 for both; C-statistic = 0.815 for ASCERT and 0.781 for PROM). Prolonged ventilation, stroke, and hospital length of stay were also predictive of long-term death.The ASCERT survival probability calculator was externally validated for prediction of long-term survival after coronary artery bypass grafting in all risk groups. The widely used STS PROM performed comparably as a predictor of long-term survival. Both tools provide important information for preoperative decision making and patient counseling about potential outcomes after coronary artery bypass grafting.

Background and Aim of the Study We studied patients presenting for coronary artery bypass grafting (CABG) with significant left main coronary artery disease (LMD) despite previously documented minimal or no LMD at percutaneous coronary intervention (PCI) for left-sided branch coronary artery disease. Methods Patients undergoing CABG for LMD with previous PCI were separated into fast or slow stenosis progression using percent change in LMD from first PCI to CABG divided by time (progression velocity). Outcomes and Kaplan–Meier survival were compared between the two groups. Results Between September 1997 and June 2010, 4837 patients underwent CABG with 1235 of them having previous PCI of which 118 had LMD and previous left-sided branch PCI. Using median progression velocity fast and slow progression groups were identified (0.53 ± 0.18 and 4.5 ± 4.8%/month, p

Objectives The clinical guidelines for asymptomatic patients with chronic mitral regurgitation (MR) use the ejection fraction (EF) to trigger surgical referral. We hypothesized that the EF is not sensitive enough to detect the earliest contractile injury in chronic MR and that the injury associated with chronic MR is not global but heterogeneous, occurring regionally and predictably, before the onset of global left ventricular (LV) dysfunction. Methods Fifteen patients with chronic MR and normal LVEF by echocardiography underwent cardiac magnetic resonance imaging with tissue tagging. Point-specific comparisons (at 15,300 LV grid points) of multiple strain parameters to a normal human strain database allowed normalization of patient-specific regional contractile function. Data were mapped over patient-specific 3-dimensional geometry and averaged across 6 LV regions. Results Global LV longitudinal and circumferential myocardial strains were normal for all 15 patients with MR compared with normal controls ( P > .05). Despite preserved global function, the anteroseptum and posteroseptum demonstrated significantly worse contractile function compared with other LV regions ( P = .003 and P = .035, respectively). Hypercontractile regions (lateral walls) appeared to compensate ( P = .002) for the reduced septal contractile function, masking injury detection by global indexes. Conclusions The earliest contractile injury seen in patients with MR is heterogeneous and consistently distributed along the LV septum. Compensatory responses include hypercontractility of other regions. These data suggest that rather than relying on global LV contractile metrics, which cannot detect early injury, patients might be better served by undergoing directed surveillance of "sentinel" LV regions (LV septum) with high-resolution metrics of regional contractile function.

Objectives The goal of this study was to determine whether a less-invasive approach to aortic valve replacement (AVR) improves clinical outcomes in diabetic patients with aortic stenosis (AS). Background Diabetes is associated with increased morbidity and mortality after surgical AVR for AS. Methods Among treated patients with severe symptomatic AS at high risk for surgery in the PARTNER (Placement of Aortic Transcatheter Valve) trial, we examined outcomes stratified according to diabetes status of patients randomly assigned to receive transcatheter or surgical AVR. The primary outcome was all-cause mortality at 1 year. Results Among 657 patients enrolled in PARTNER who underwent treatment, there were 275 patients with diabetes (145 transcatheter, 130 surgical). There was a significant interaction between diabetes and treatment group for 1-year all-cause mortality (p = 0.048). Among diabetic patients, all-cause mortality at 1 year was 18.0% in the transcatheter group and 27.4% in the surgical group (hazard ratio: 0.60 [95% confidence interval: 0.36 to 0.99]; p = 0.04). Results were consistent among patients treated via transfemoral or transapical routes. In contrast, among nondiabetic patients, there was no significant difference in all-cause mortality at 1 year (p = 0.48). Among diabetic patients, the 1-year rates of stroke were similar between treatment groups (3.5% transcatheter vs. 3.5% surgery; p = 0.88), but the rate of renal failure requiring dialysis >30 days was lower in the transcatheter group (0% vs. 6.1%; p = 0.003). Conclusions Among patients with diabetes and severe symptomatic AS at high risk for surgery, this post-hoc stratified analysis of the PARTNER trial suggests there is a survival benefit, no increase in stroke, and less renal failure from treatment with transcatheter AVR compared with surgical AVR. (The PARTNER Trial: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894 )

Cardiovascular disease and cancer are leading causes of death in the United States and commonly co-occur due to shared patient risk factors. The optimal management strategy for acute coronary syndromes in patients with cancer-related thrombocytopenia is not established. A 71-year-old male with

Coronary artery disease (CAD) is encountered in 40-75% of those undergoing transcatheter aortic valve replacement (TAVR). However, the safety of percutaneous coronary intervention (PCI) prior to TAVR is unclear. A retrospective analysis of patients with PCI < 6 months prior to TAVR from 1/1/2013- 1

The observed-to-expected 30-day mortality ratio (O:E ratio) is a standard metric by which transcatheter aortic valve replacement (TAVR) trials have been evaluated. Early TAVR trials consistently demonstrated O:E ratio less than 0.6 after TAVR when based on the Society for Thoracic Surgery Predicted Risk of Mortality (STS-PROM) for surgical aortic valve replacement. Recent published results from the Transcatheter Valve Therapy (TVT) Registry have demonstrated O:E ratios of 1.0. We evaluated our own O:E ratios for TAVR to investigate this discordance.Data were collected prospectively for TAVR patients from 2008 through 2015 (N = 546) and were reviewed retrospectively. The observed mortality and STS-PROM were calculated to formulate O:E ratios and were compared over a variety of subgroups.Overall, the O:E ratio for 30-day mortality was 0.4 and significantly less than 1 (P .001; 95% confidence interval, 0.25-0.63). The O:E ratio relationship remained less than 0.5 for patients with low (STS-PROM 4), moderate (STS-PROM = 4-8) and high risk (STS-PROM 8). The O:E ratio was significantly higher for transapical patients (O:E ratio = 0.8) when compared with transfemoral patients (O:E ratio = 0.2). Lastly, O:E ratios for both commercial (O:E ratio = 0.5) and research (O:E ratio = 0.3) patients were similar (P = .337), and both were significantly less than 1 (P = .007 and P .001, respectively).The STS-PROM consistently overestimated 30-day mortality after TAVR. Achieving an O:E ratio less than 0.6 may be a realistic goal for all TAVR programs. While an accurate and specific risk calculator for 30-day mortality after TAVR remains to be established, our data suggest that current TVT results are not acceptable for commercial TAVR and that programs with an O:E ratio greater than 0.6, based on the STS-PROM, should reevaluate internal processes to improve their results.

Background— The Placement of Aortic Transcatheter Valves (PARTNER) trial demonstrated similar survival after transcatheter and surgical aortic valve replacement (TAVR and SAVR, respectively) in high-risk patients with symptomatic, severe aortic stenosis. The aim of this study was to evaluate the effect of left ventricular (LV) dysfunction on clinical outcomes after TAVR and SAVR and the impact of aortic valve replacement technique on LV function. Methods and Results— The PARTNER trial randomized high-risk patients with severe aortic stenosis to TAVR or SAVR. Patients were stratified by the presence of LV ejection fraction (LVEF) P P P Conclusions— In high-risk patients with severe aortic stenosis and LV dysfunction, mortality rates and LV functional recovery were comparable between valve replacement techniques. TAVR is a feasible alternative for patients with symptomatic severe aortic stenosis and LV dysfunction who are at high risk for SAVR. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894.

Racial disparities exist in the treatment of many cardiovascular diseases. Aortic valve replacement (AVR) is the only treatment for aortic stenosis (AS) that improves patient symptoms and survival. To date, no studies have compared the rate of AVR among different races. The records of patients with an aortic valve area1 cm(2) by echocardiography diagnosed between January 2004 and May 2010 at Barnes-Jewish Hospital were reviewed retrospectively. Patients were stratified by race. Of the 880 patients analyzed, 10% were African American (AA), and 90% were European American (EA). AA more frequently had hypertension (82% vs 67%, p0.01), diabetes mellitus (45% vs 32%, p = 0.02), chronic kidney disease (28% vs 17%, p = 0.01), and end stage renal disease (18% vs 2%, p0.001). AA underwent AVR less frequently than EA (39% vs 53%, p = 0.02) and refused intervention more often (33% vs 20%, p = 0.04). When treated, AA and EA had similar 3-year survival (49% [38 to 60] vs 50% [45 to 54], p = 0.31). Identification of the factors associated with treatment refusal would further our ability to counsel patients on the decision to pursue AVR.

The incidence of and causes for permanent pacemaker implantation (PPM) after surgical arrhythmia procedures remain poorly understood because of the varied lesion patterns and energy sources reported in small series. This study characterized the incidence, indications, and risk factors for PPM after the Cox-maze IV (CMIV) procedure when performed as either a lone or a concomitant procedure.A retrospective analysis of 340 patients undergoing a CMIV as either a lone (n = 112) or a concomitant (n = 228) procedure was conducted. The incidence, indication, and variables associated with PPM implantation within 1 year of the operation were assessed. Follow-up was conducted at 30 days and 1 year and was 90% complete.The incidence of PPM after a lone CMIV procedure was 5%. Patients with concomitant cardiac operations had a nonsignificant increase in PPM insertion at 30 days (11% vs 5%, p = 0.14) and 1 year (15% vs 6%, p = 0.06) when compared with lone CMIV patients. Of patients who required pacemakers, sinus node dysfunction was present in 79% (35/44) of patients in the entire series and in 88% (8/9) after lone CMIV. After PPM, 84% (37/44) of patients remained paced at last follow-up. Multivariate analysis identified age (odds ratio = 1.10 [1.06-1.14], p0.001) as the only variable associated with higher risk of a PPM after any CMIV procedure.The risk of PPM implantation after a lone CMIV is 5% and increases with age. The need for a PPM after a CMIV is largely due to SA node dysfunction, which appears unlikely to recover. These data should help physicians counsel patients regarding the perioperative risks associated with the CMIV.

The use of surgical lesion sets for the treatment of atrial fibrillation has been increasing, particularly in patients with complicated anatomical substrates and those undergoing concomitant surgery. Preferences in terms of lesion set, surgical approach and ablation technology vary by center. This review discusses both the surgical techniques and the outcomes for the most commonly performed procedures in the context of recent consensus guidelines. The Cox-Maze IV, pulmonary vein isolation, extended left atrial lesion sets, the hybrid approach and ganglionated plexus ablation are each reviewed in an attempt to provide insight into current clinical practice and patient selection.

Background Smaller transcatheter aortic valve replacement (TAVR) delivery systems have increased the number of patients eligible for transfemoral procedures while decreasing the need for transaortic (TAo) or transapical (TA) access. As a result, newer TAVR centers are likely to have less exposure to these alternative access techniques, making it harder to achieve proficiency. The purpose of this study was to evaluate the learning curve for TAVR approaches and compare perioperative outcomes. Methods From January 2008 to December 2014, 400 patients underwent TAVR (transfemoral, n = 179; TA, n = 120; and TAo, n = 101)). Learning curves were constructed using metrics of contrast utilization, procedural, and fluoroscopy times. Outcomes during the learning curve were compared with after proficiency was achieved. Results Depending on the metric, learning curves for all three routes differed slightly but all demonstrated proficiency by the 50th case. There were no significant differences in procedural times whereas improvements in contrast use were most notable for TA (69 ± 40 mL versus 50 ± 23 mL, p = 0.002). For both TA and TAo, fewer patients received transfusions once proficiency was reached (62% versus 34%, p = 0.003, and 42% versus 14%, p = 0.002, respectively). No differences in 30-day or 1-year mortality were seen before or after proficiency was reached for any approach. Conclusions The learning curves for TA and TAo are distinct but technical proficiency begins to develop by 25 cases and becomes complete by 50 cases for both approaches. Given the relatively low volume of alternative access, achieving technical proficiency may take significant time. However, technical proficiency had no effect on 30-day or 1-year mortality for any access approach.

Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time.One thousand seven hundred thirty-two patients undergoing surgery for type A aortic dissection were identified from the International Registry of Acute Aortic Dissection Interventional Cohort Database. Patients were divided into time tertiles (T) (T1: 1996-2003, T2: 2004-2010, and T3: 2011-2016).Frequency of valve sparing procures increased (T1: 3.9%, T2: 18.6%, and T3: 26.7%; trend P .001). Biologic valves were increasingly utilized (T1: 35.6%, T2; 40.6%, and T3: 52.0%; trend P = .009), whereas mechanical valve use decreased (T1: 57.6%, T2: 58.0%, and T3: 45.4%; trend P = .027) for aortic valve replacement. Adjunctive cerebral perfusion use increased (T1: 67.1%, T2: 89.5%, and T3: 84.8%; trend P .001), with increase in antegrade cerebral techniques (T1: 55.9%, T2: 58.8%, and T3: 66.1%; trend P = .005) and hypothermic circulatory arrest (T1: 80.1%, T2: 85.9%, and T3: 86.8%; trend P = .030). Arterial perfusion through axillary cannulation increased (T1: 18.0%, T2: 33.2%, and T3: 55.7%), whereas perfusion via a femoral approach diminished (T1: 76.0%, T2: 53.3%, and T3: 30.1%) (both P values .001). Hemiarch replacement was utilized more frequently (T1: 27.0%, T2: 63.3%, and T3: 51.7%; trend P = .001) and partial arch was utilized less frequently (T1: 20.7%, T2: 12.0%, and T3: 8.4%; trend P .001), whereas complete arch replacement was used similarly (P = .131). In-hospital mortality significantly decreased (T1: 17.5%, T2: 15.8%, and T3: 12.2%; trend P = .017).There have been significant changes in operative strategy over time in the management of type A aortic dissection, with more frequent use of valve-sparing procedures, bioprosthetic aortic valve substitutes, antegrade cerebral perfusion strategies, and hypothermic circulatory arrest. Most importantly, a significant decrease of in-hospital mortality was observed during the 20-year timespan.

Background Although preoperative renal dysfunction (RD) is associated with increased mortality and morbidity after surgical aortic valve replacement, its impact on clinical outcomes after transcatheter aortic valve replacement (TAVR) is less defined. Methods TAVR patients in the PARTNER (Placement of Aortic Transcatheter Valves) trial with a calculable glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease equation were included. Patients were divided into three groups: GFR >60 mL/min (none/mild RD), GFR 31 to 60 mL/min (moderate RD), and GFR ≤30 mL/min (severe RD). Operative characteristics and clinical outcomes were analyzed. Cox regression models were used to determine multivariable predictors of 1-year all-cause mortality. Results A total of 2,531 inoperable or high surgical risk patients from the PARTNER trial and continued access registries had a calculable GFR level: 767 (30%) had normal renal function or mild RD, 1,473 (58%) had moderate RD, and 291 (12%) presented with severe RD. The mean Society of Thoracic Surgeons Predicted Risk of Mortality for the cohort was 11.5%, and it was highest in those with severe RD (13.8%). Patients with severe RD were more often women with a higher prevalence of diabetes. Patients with severe RD had the highest incidence of 30-day and 1-year all-cause mortality and rehospitalization. The 30-day rate of death from any cause was 10.7% in the severe RD group versus 6.0% in the moderate and mild RD groups ( p = 0.01). The 1-year rate of death from any cause was 34.4% in the severe RD group versus 21.5% in the moderate RD and 20.8% in the none/mild RD groups (adjusted hazard ratio [HR] 2.24, p p = 0.24 for severe versus moderate). Other significant predictors of 1-year all-cause mortality included lower body mass index, frailty, the transapical approach, a lower ejection fraction, oxygen-dependent chronic obstructive pulmonary disease, liver disease, and male sex. Conclusions Preoperative severe RD is a significant predictor for 1-year mortality in TAVR patients. Careful risk stratification by the heart team is required in patients with severe preprocedural RD.

Transcatheter valve implantation via the transfemoral approach has steadily evolved over the past decade. With the publication of large, multicenter trials evaluating the first-generation devices, it is clear that transcatheter valve implantation is a safe and effective treatment for aortic valve disease. However, several shortcomings have been identified: high incidences of cerebrovascular accidents, vascular complications, rhythm disturbances, paravalvular regurgitation, and malposition. These shortcomings combined with expanding indications have stimulated many companies to produce new second-generation devices aimed at reducing or eliminating these deficiencies. In particular, some second-generation transfemoral devices have been designed to be delivered through sheaths as small as 14 French with the ability to be repositioned and retrieved. With new devices being produced at an exponential rate both in the United States and throughout the entire world, evaluating each new device through rigorous preclinical and clinical trials is essential. Once safety and efficacy are confirmed, indications are well established, and technology has sufficiently matured, large randomized trials will be necessary to compare each transcatheter device.

Increased right atrial (RA) and ventricular (RV) chamber volumes are a late maladaptive response to chronic pulmonary hypertension. The purpose of the current investigation was to characterize the early compensatory changes that occur in the right heart during chronic RV pressure overload before the development of chamber dilation. Magnetic resonance imaging with radiofrequency tissue tagging was performed on dogs at baseline and after 10 wk of pulmonary artery banding to yield either mild RV pressure overload (36% rise in RV pressure; n = 5) or severe overload (250% rise in RV pressure; n = 4). The RV free wall was divided into three segments within a midventricular plane, and circumferential myocardial strain was calculated for each segment, the septum, and the left ventricle. Chamber volumes were calculated from stacked MRI images, and RA mechanics were characterized by calculating the RA reservoir, conduit, and pump contribution to RV filling. With mild RV overload, there were no changes in RV strain or RA function. With severe RV overload, RV circumferential strain diminished by 62% anterior ( P = 0.04), 42% inferior ( P = 0.03), and 50% in the septum ( P = 0.02), with no change in the left ventricle ( P = 0.12). RV filling became more dependent on RA conduit function, which increased from 30 ± 9 to 43 ± 13% ( P = 0.01), than on RA reservoir function, which decreased from 47 ± 6 to 33 ± 4% ( P = 0.04), with no change in RA pump function ( P = 0.94). RA and RV volumes and RV ejection fraction were unchanged from baseline during either mild ( P > 0.10) or severe RV pressure overload ( P > 0.53). In response to severe RV pressure overload, RV myocardial strain is segmentally diminished and RV filling becomes more dependent on RA conduit rather than reservoir function. These compensatory mechanisms of the right heart occur early in chronic RV pressure overload before chamber dilation develops.

The Cox-maze III procedure (CMP) has achieved high success rates for the surgical treatment of atrial fibrillation (AF). In 2002, our group introduced a simplified CMP, in which most incisions were replaced with linear lines of ablation using bipolar radiofrequency and cryoenergy. This operation, termed the CMP-IV, has significantly shortened operative times and allowed for a minimally invasive approach. This report evaluates our results in 100 consecutive patients undergoing a stand-alone CMP-IV.Data were collected prospectively on 100 patients (mean age, 56 ± 10 years) who underwent a CMP-IV from January 2002 through May 2010. All patients were available for follow-up with a mean follow-up of 17 ± 10 months. Electrocardiograms or 24-h Holter monitorings were obtained at 6, 12, and 24 months. Data were analyzed using a longitudinal database containing over 380 variables.Thirty-one percent of patients had paroxysmal AF, with the remainder having persistent (6%) or longstanding persistent AF (63%). The mean preoperative duration of AF was 7.4 ± 6.7 years. The mean left atrial diameter was 4.7 ± 1.1 cm. In this group, 40 patients had failed with a mean of 2.6 ± 1.3 catheter ablations. Mean aortic cross-clamp time was 41 ± 13 min. There was one postoperative mortality. Postoperative freedom from AF was 93%, 90%, and 90% at 6, 12, and 24 months, respectively. Freedom from AF off antiarrhythmic medication was 82%, 82%, and 84% at 6, 12, and 24 months, respectively.The less invasive CMP-IV has a high single procedure success rate, even with improved follow-up and stricter definitions of failure.

The purpose of this study was to determine the impact of prosthesis-patient mismatch on long-term survival after mitral valve replacement.From 1992 to 2008, 765 patients underwent bioprosthetic (325; 42%) or mechanical (440; 58%) mitral valve replacement, including 370 (48%) patients older than 65 years of age. Prosthesis-patient mismatch was defined as severe (prosthetic effective orifice area to body surface area ratio0.9 cm(2)/m(2)), moderate (0.9 to 1.2 cm(2)/m(2)), or absent (1.2 cm(2)/m(2)).Multivariate analysis identified nine risk factors for late death including advanced age, earlier operative year, chronic renal insufficiency, peripheral vascular disease, congestive heart failure, nonrheumatic origin, concomitant coronary artery bypass grafting, lower body surface area, and more severe prosthesis-patient mismatch (lower effective orifice area to body surface area ratio; p0.05). For bioprosthetic recipients older than 65 years of age, survival at 5 and 10 years was 30% ± 7% and 0% ± 0% with severe mismatch compared with 43% ± 4% and 21% ± 5% for absent or moderate mismatch, respectively (p = 0.05). For mechanical recipients younger than 65 years of age, survival at 5 and 10 years was 77% ± 4% and 62% ± 6% with moderate or severe mismatch compared with 82% ± 3% and 66% ± 4%, respectively, without mismatch (p = 0.08).Severe mismatch adversely affected long-term survival for older patients receiving bioprosthetic valves. With mechanical valves, there was a trend toward impaired survival when mismatch was moderate or severe in younger patients. Thus, selection of an appropriate mitral prosthesis warrants careful consideration of age and valve type.

ObjectivesThe purpose of this study was to determine the safety and effectiveness of the SAPIEN XT versus SAPIEN systems (Edwards Lifesciences, Irvine, California) in patients with symptomatic, severe aortic stenosis (AS) who were not candidates for surgery.BackgroundTranscatheter aortic valve replacement (TAVR) has become the standard of care for inoperable patients with severe, symptomatic AS. In the PARTNER (Placement of Aortic Transcatheter Valves) IB trial, a reduction in all-cause mortality was observed in patients undergoing TAVR with the balloon-expandable SAPIEN transcatheter heart valve compared with standard therapy, but the SAPIEN valve was associated with adverse periprocedural complications, including vascular complications, major bleeding, and paravalvular regurgitation. The newer, low-profile SAPIEN XT system was developed to reduce these adverse events.MethodsA total of 560 patients were enrolled at 28 sites in the United States from April 2011 to February 2012. Patients were randomized to receive the SAPIEN or SAPIEN XT systems. The primary endpoint was a nonhierarchical composite of all-cause mortality, major stroke, and rehospitalization at 1 year in the intention-to-treat population, assessed by noninferiority testing. Pre-specified secondary endpoints included cardiovascular death, New York Heart Association functional class, myocardial infarction, stroke, acute kidney injury, vascular complications, bleeding, 6-min walk distance, and valve performance (by echocardiography).ResultsBoth overall and major vascular complications were higher at 30 days in patients undergoing TAVR with SAPIEN compared with SAPIEN XT (overall: 22.1% vs. 15.5%; p = 0.04; major: 15.2% vs. 9.5%; p = 0.04). Bleeding requiring blood transfusions was also more frequent with SAPIEN compared with SAPIEN XT (10.6% vs. 5.3%; p = 0.02). At 1-year follow-up, the nonhierarchical composite of all-cause mortality, major stroke, or rehospitalization was similar (37.7% SAPIEN vs. 37.2% SAPIEN XT; noninferiority p value

To determine the role of preoperative pulmonary function tests (PFTs) in patients with aortic stenosis (AS) evaluated for aortic valve replacement (AVR), and to evaluate the association between lung disease and mortality in specific subgroups.Between 2008 and 2013, 535 patients with preoperative PFTs underwent AVR (transcatheter AVR [TAVR], n = 246; surgical AVR [SAVR], n = 289). The severity of lung disease determined by the Society of Thoracic Surgeons (STS) definition was evaluated in those with and without a clinical suspicion for lung disease (smoking, inhaled steroids/bronchodilators, or home oxygen). The association between lung disease and 1-year mortality was evaluated.Of the 186 patients (35%) without suspected lung disease, 39 (21%) had moderate/severe lung disease by PFT analysis. Among all patients, 1-year mortality was 12% in those with no lung disease, 17% in those with no mild lung disease, 22% in those with moderate lung disease, and 31% in those with severe lung disease (P.001, log-rank test). After adjustment, moderate/severe lung disease was associated with increased 1-year mortality (adjusted hazard ratio, 2.07; 95% confidence interval, 1.30-3.29; P = .002); this association was not altered by smoking history, suspicion of lung disease, New York Heart Association class, or AVR type (interaction P value nonsignificant for all).In patients with AS evaluated for AVR, the STS risk score is significantly influenced by the severity of lung disease, which is determined predominantly by PFT results. Even when lung disease is not suspected, PFTs are abnormal in many patients undergoing AVR. Moderate/severe lung disease, diagnosed predominantly by PFTs, is an independent predictor of mortality after SAVR or TAVR. Collectively, these findings suggest that PFTs should be a routine part of the risk stratification of patients considered for AVR.