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From November, 1973, through June, 1978, 428 operations in 425 patients were performed for replacement of aortic, mitral, or aortic plus mitral valves, utilizing 277 Hancock and 180 Carpentier-Edwards bioprostheses. Actuarially determined survival at 36 months was similar for all three groups and compared favorably with our experience with the Björk-Shiley prosthesis. Certain patient-related variables influencing late survival were identified by multivariate analysis and included previous operation for congenital heart disease, coronary artery bypass grafting in nonaortic valve replacement, race (black), age at operation, and New York Heart Association Functional Class. A small but definite incidence of thromboembolism occurred in all three groups, again similar to our experience with the Björk-Shiley prosthesis. Multivariate analysis identified four factors influencing risk of thromboembolism: previous cardiac operation, age, double-valve replacement, and rhythm at discharge. Valve degeneraation occurred, primarily in children and young adults. Over the medium term, the porcine bioprosthesis compared favorably with mechanical prostheses in terms of survival, function, and thromboembolism. Certain patient-related variables affecting survival may be modified by earlier surgical intervention.

BACKGROUND- Simultaneous contribution of hundreds of electrocardiographic (ECG) biomarkers to prediction of long-term mortality in postmenopausal women with clinically normal resting ECGs is unknown. METHODS AND RESULTS- We analyzed ECGs and all-cause mortality in 33 144 women enrolled in the Women's Health Initiative trials who were without baseline cardiovascular disease or cancer and had normal ECGs by Minnesota and Novacode criteria. Four hundred and seventy-seven ECG biomarkers, encompassing global and individual ECG findings, were measured with computer algorithms. During a median follow-up of 8.1 years (range for survivors, 0.5 to 11.2 years), 1229 women died. For analyses, the cohort was randomly split into derivation (n=22 096; deaths, 819) and validation (n=11 048; deaths, 410) subsets. ECG biomarkers and demographic and clinical characteristics were simultaneously analyzed using both traditional Cox regression and random survival forest, a novel algorithmic machine-learning approach. Regression modeling failed to converge. Random survival forest variable selection yielded 20 variables that were independently predictive of long-term mortality, 14 of which were ECG biomarkers related to autonomic tone, atrial conduction, and ventricular depolarization and repolarization. CONCLUSIONS- We identified 14 ECG biomarkers from among hundreds that were associated with long-term prognosis using a novel random forest variable selection methodology. These biomarkers were related to autonomic tone, atrial conduction, ventricular depolarization, and ventricular repolarization. Quantitative ECG biomarkers have prognostic importance and may be markers of subclinical disease in apparently healthy postmenopausal women. [ABSTRACT FROM AUTHOR]

Context: Stroke is a devastating and potentially preventable complication of coronary artery bypass graft (CABG) surgery. Better understanding of the timing and risk factors for stroke associated with CABG are needed.Objectives: To investigate temporal trends in stroke after CABG and to identify stroke risk factors and association with longitudinal outcomes.Design, Setting, and Patients: Prospective study conducted from 1982 through 2009 at a single US academic medical center among 45,432 consecutive patients (mean age, 63 [SD, 10] years) undergoing isolated primary or reoperative CABG surgery. Strokes occurring following CABG were recorded prospectively and classified as having occurred intraoperatively or postoperatively. Complications and survival after stroke were assessed in propensity-matched groups.Intervention: CABG performed using 4 different operative strategies (off-pump, on-pump with beating heart, on-pump with arrested heart, on-pump with hypothermic circulatory arrest).Main Outcome Measures: Hospital complications; late survival.Results: Among 45,432 patients undergoing CABG surgery, 705 (1.6% [95% confidence interval {CI}, 1.4%-1.7%]) experienced a stroke. The prevalence of stroke peaked in 1988 at 2.6% (95% CI, 1.9%-3.4%), then declined at 4.69% (95% CI, 4.68%-4.70%) per year (P = .04), despite increasing patient comorbidity. Overall, 279 strokes (40%) occurred intraoperatively and 409 (58%) occurred postoperatively (timing indeterminate in 17 patients). Postoperative stroke peaked at 40 hours, decreasing to 0.055%/d (95% CI, 0.047%-0.065%) by day 6. Risk factors for both intraoperative and postoperative stroke included older age (odds ratio, 8.5 [95% CI, 3.2-22]) and variables representing arteriosclerotic burden. Intraoperative stroke rates were lowest in off-pump CABG (0.14% [95% CI, 0.029%-0.40%]) and on-pump beating-heart CABG (0% [95% CI, 0%-1.6%]), intermediate with on-pump arrested-heart CABG (0.50% [95% CI, 0.41%-0.61%]), and highest with on-pump CABG with hypothermic circulatory arrest (5.3% [95% CI, 2.0%-11%]). Patients with stroke had worse adjusted hospital outcomes, longer intensive care and postoperative stays, and worse downstream survival (mean, 11 [SD, 8.6] years).Conclusion: Among patients undergoing CABG surgery at a single center over the past 30 years, the occurrence of stroke declined despite an increasing patient risk profile, and more than half of strokes occurred postoperatively rather than intraoperatively. [ABSTRACT FROM AUTHOR]

Objectives: We sought to determine whether abnormal heart rate recovery predicts mortality independent of the angiographic severity of coronary disease.Background: An attenuated decrease in heart rate after exercise, or heart rate recovery (HRR), has been shown to predict mortality. There are few data on its prognostic significance once the angiographic severity of coronary artery disease (CAD) is ascertained.Methods: For six years we followed 2,935 consecutive patients who underwent symptom-limited exercise testing for suspected CAD and then had a coronary angiogram within 90 days. The HRR was abnormal if < or =12 beats/min during the first minute after exercise, except among patients undergoing stress echocardiography, in whom the cutoff was < or =18 beats/min. Angiographic CAD was considered severe if the Duke CAD Prognostic Severity Index was > or =42 (on a scale of 0 to 100), which corresponds to a level of CAD where revascularization is associated with better long-term survival.Results: Severe CAD was present in 421 patients (14%), whereas abnormal HRR was noted in 838 patients (29%). There were 336 deaths (11%). Mortality was predicted by abnormal HRR (hazard ratio [HR] 2.5, 95% confidence interval [CI] 2.0 to 3.1; p < 0.0001) and by severe CAD (HR 2.0, 95% CI 1.6 to 2.6; p < 0.0001); both variables provided additive prognostic information. After adjusting for age, gender, standard risk factors, medications, exercise capacity, and left ventricular function, abnormal HRR remained predictive of death (adjusted HR 1.6, 95% CI 1.2 to 2.0; p < 0.0001); severe CAD was also predictive (adjusted HR 1.4, 95% CI 1.1 to 1.9; p = 0.008).Conclusions: Even after taking into account the angiographic severity of CAD, left ventricular function, and exercise capacity, HRR is independently predictive of mortality. [ABSTRACT FROM AUTHOR]

Objectives: The goal of this study was to determine the prognostic significance of estimated creatinine clearance (CrCl) in relation to 6-min walk distance in ambulatory patients with congestive heart failure (HF).Background: Although measurement of renal function is integral to the management of chronic congestive HF, its prognostic implications are not well described and have not been formally evaluated relative to measures of functional capacity.Methods: We analyzed outcomes of the 585 participants of the 6-min walk substudy of the Digitalis Investigation Group (DIG) trial. The CrCl was estimated using the Cockcroft-Gault equation. Predictors of all-cause mortality were identified using semiparametric Cox proportional hazards regression and completely parametric hazard analyses.Results: Most subjects (85%) were New York Heart Association functional class II and III. Mean age was 65 (+/-12) years and mean ejection fraction (EF) 35% (+/-13%). There were 153 (26%) deaths during a median of 2.6 years of follow-up. Mortality by increasing quartiles of estimated CrCl was 37% (18 to 48 ml/min), 29% (47 to 64 ml/min), 18% (64 to 86 ml/min), and 21% (86 to 194 ml/min) with corresponding hazard ratios (HRs) relative to the top quartile of 2.1 (95% confidence interval [CI], 1.4 to 3.3), 1.6 (95% CI, 1.0 to 2.5), and 0.9 (95% CI, 0.5 to 1.5), respectively. In Cox regression analyses, independent predictors of mortality were estimated CrCl (adjusted HR [quartile 1:quartile 4] 1.5; 95% CI, 1.1 to 2.1), 6-min walk distance < or =262 m [adjusted HR, 1.63; 95% CI, 1.12 to 2.27]), EF, recent hospitalization for worsening HF, and need for diuretic treatment. Parametric (hazard) analysis confirmed consistent effects of estimated CrCl on mortality in several subgroups including that of patients with EF >45%.Conclusion: In ambulatory patients with congestive HF, estimated CrCl predicts all-cause mortality independently of established prognostic variables. [ABSTRACT FROM AUTHOR]

Context: Although aspirin has been shown to reduce cardiovascular morbidity and short-term mortality following acute myocardial infarction, the association between its use and long-term all-cause mortality has not been well defined.Objectives: To determine whether aspirin is associated with a mortality benefit in stable patients with known or suspected coronary disease and to identify patient characteristics that predict the maximum absolute mortality benefit from aspirin.Design and Setting: Prospective, nonrandomized, observational cohort study conducted between 1990 and 1998 at an academic medical institution, with a median follow-up of 3.1 years.Patients: Of 6174 consecutive adults undergoing stress echocardiography for evaluation of known or suspected coronary disease, 2310 (37%) were taking aspirin. Patients with significant valvular disease or documented contraindication to aspirin use, including peptic ulcer disease, renal insufficiency, and use of nonsteroidal anti-inflammatory drugs, were excluded.Main Outcome Measure: All-cause mortality according to aspirin use.Results: During 3.1 years of follow-up, 276 patients (4.5%) died. In a simple univariable analysis, there was no association between aspirin use and mortality (4.5% vs 4.5%). However, after adjustment for age, sex, standard cardiovascular risk factors, use of other medications, coronary disease history, ejection fraction, exercise capacity, heart rate recovery, and echocardiographic ischemia, aspirin use was associated with reduced mortality (hazard ratio [HR], 0.67; 95% confidence interval [CI], 0.51-0.87; P =.002). In further analysis using matching by propensity score, 1351 patients who were taking aspirin were at lower risk for death than 1351 patients not using aspirin (4% vs 8%, respectively; HR, 0.53; 95% CI, 0.38-0.74; P =.002). After adjusting for the propensity for using aspirin, as well as other possible confounders and interactions, aspirin use remained associated with a lower risk for death (adjusted HR, 0.56; 95% CI, 0.40-0.78; P<.001). The patient characteristics associated with the most aspirin-related reductions in mortality were older age, known coronary artery disease, and impaired exercise capacity.Conclusion: Aspirin use among patients undergoing stress echocardiography was independently associated with reduced long-term all-cause mortality, particularly among older patients, those with known coronary artery disease, and those with impaired exercise capacity. [ABSTRACT FROM AUTHOR]

Background: Abnormal heart rate recovery after symptom-limited exercise predicts death. It is unknown whether this is also true among patients undergoing submaximal testing.Objective: To test the prognostic implications of heart rate recovery in cardiovascularly healthy adults undergoing submaximal exercise testing.Design: Population-based cohort study.Setting: 10 primary care sites.Participants: 5234 adults without evidence of cardiovascular disease who were enrolled in the Lipid Research Clinics Prevalence Study.Measurements: Heart rate recovery was defined as the change from peak heart rate to that measured 2 minutes later (heart rate recovery was defined as < or =42 beats/min).Results: During 12 years of follow-up, 312 participants died. Abnormal heart rate recovery predicted death (relative risk, 2.58 [CI, 2.06 to 3.20]). After adjustment for standard risk factors, fitness, and resting and exercise heart rates, abnormal heart rate recovery remained predictive (adjusted relative risk, 1.55 [CI, 1.22 to 1.98]) (P<0.001).Conclusion: Even after submaximal exercise, abnormal heart rate recovery predicts death. [ABSTRACT FROM AUTHOR]

Objectives: To localize and quantify mitral calcification associated with severe aortic stenosis and severe mitral regurgitation and determine its association with cardiac remodeling, operative management, and long-term survival., Methods: From July 1998 to July 2010, 158 patients with severe aortic stenosis, severe mitral regurgitation, and mitral calcification underwent surgical aortic valve replacement (SAVR, n=49) or SAVR plus mitral valve repair (SAVR+MVr, n=67) or replacement (SAVR+MVR, n=42). Mitral calcium was localized and quantified on preoperative computed tomography. Random forest methodology was used to correlate calcium volume with cardiac morphology and function. Median follow-up for survival was 4.1 years; 25% were followed ≥14 years., Results: Larger calcium volume was associated with degenerative mitral disease, higher ejection fraction, smaller left ventricular end-systolic volume, and SAVR+MVR (median calcium volume 3.4 cm 3 ) versus SAVR (median calcium volume 1.0 cm 3 ) or SAVR+MVr (median calcium volume 0.41 cm 3 ). Ten-year mortality was higher in patients with more mitral calcification (terciles: 7.1% vs 16% vs 25%), subvalvular involvement (8.1% vs 18%), and SAVR+MVR (5.4% vs SAVR=13% vs SAVR+MVr=26%). Multivariable analysis demonstrated early postoperative mortality was strongly associated with subvalvular mitral calcification, but late mortality was not associated with calcium volume or location., Conclusions: Larger mitral calcium volume is a marker of late-stage cardiac remodeling associated with more extensive mitral valve intervention, but it is not associated with long-term mortality. Quantitative analysis of mitral calcification with computed tomography can aid in patient selection and surgical management decisions in this complex patient population., (Copyright © 2024. Published by Elsevier Inc.)

Background: Impella 5.5 is a temporary left ventricular assist device utilized to support patients with cardiogenic shock and those undergoing high-risk cardiac interventions., Methods: From October 2019 to January 2023, 226 patients received Impella 5.5 support at Cleveland Clinic main campus. Patients were stratified by Society for Cardiovascular Angiography and Interventions (SCAI) shock stages. Immediate post-Impella 5.5 trajectories were compared across groups. Trajectories were defined as mortality on Impella 5.5, transition to advanced heart failure therapies (durable left ventricular assist device/heart transplantation), or survival to Impella 5.5 removal without advanced therapies., Results: Overall, 148 (65%) patients with cardiogenic shock and 78 (35%) undergoing high-risk cardiac interventions received Impella 5.5 support. SCAI stage was A in 63 (28%), B in 10 (4.4%), C in 29 (13%), D in 104 (46%), and E in 20 (8.8%). Mortality on Impella 5.5 was highest in SCAI stage E (A: 3.2%, B: 10%, C: 14%, D: 27%, E: 35%; p < 0.01). Transition to advanced therapies (durable left ventricular assist device or heart transplantation) was highest in SCAI stages C-D (A: 1.6%, B: 0.0%, C: 45%, D: 36%, E: 20%; p < 0.01). Survival to Impella removal without advanced therapies was highest in SCAI stages A-B (A: 95%, B: 90%, C: 41%, D: 38%, E: 45%; p < 0.01)., Conclusions: Stratification by presentation acuity in candidates for Impella 5.5 insertion may help identify which patients may and may not benefit from this escalation of tailored temporary mechanical circulatory support., (© 2024 The Author(s). Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Objective: To evaluate whether multiarterial grafting provides incremental benefit above single arterial grafting in isolated redo CABG., Methods: From 1/1980 to 7/2020, 6559 adults underwent 6693 isolated CABG reoperations. Patients undergoing multiarterial grafting were propensity-score matched with those undergoing single arterial grafting, with or without additional vein grafts, yielding 2005 well-matched pairs. Endpoints were in-hospital postoperative complications, hospital mortality, and long-term mortality. Median follow-up was 10 years with 25% followed >17 years. Multivariable multiphase hazard modeling and nonparametric random survival forests for survival were used to identify patients for whom multiarterial grafting was most beneficial., Results: Among propensity-matched patients, postoperative complications for multiarterial versus single arterial grafting were any reoperation, 50 (2.5%) versus 65 (3.2%); renal failure, 73 (3.6%) versus 55 (2.7%); stroke, 44 (2.2%) versus 38 (1.9%); and deep sternal infection, 36 (1.8%) versus 25 (1.2%). Hospital mortality was 1.7% (n=35) versus 2.8% (n=56) (P=.03). Comparing multiarterial to single arterial grafting, survival at 1 and 3 years was 95% versus 94% and 92% versus 88%, and at 5, 15, and 20 years, survival was 87%, 49%, and 31% versus 82%, 42%, and 25%. Better survival after multiarterial grafting was confined to males with 2 patent internal thoracic artery grafts (P<.0001)., Conclusions: Redo CABG with multiarterial grafting can be performed with lower in-hospital mortality and similar major morbidity to single arterial grafting. It is associated with better long-term survival, particularly in males when 2 internal thoracic artery grafts are used., (Copyright © 2024. Published by Elsevier Inc.)

Background: Current classification of achalasia does not account for variability in esophageal tortuosity. The esophageal length-to-height ratio (LHR) was developed to objectively quantify tortuosity, based on the premise that the esophagus must elongate to become tortuous. Hence, we assess the relationship of esophageal tortuosity, measured by LHR, to preoperative patient characteristics and post-myotomy outcomes, including longitudinal symptom relief and esophageal emptying., Methods: From 01/2014 to 01/2020, 420 eligible adult patients underwent myotomy for achalasia at our institution, 216 (51%) Heller myotomy and 204 (49%) per-oral endoscopic myotomy. LHR was measured on pre- and first postoperative timed barium esophagram (TBE), with larger values signifying greater tortuosity. Variable predictiveness and risk-adjusted longitudinal estimates of symptom relief (Eckardt score ≤ 3) and complete emptying, in relation to LHR and manometric subtype, were estimated., Results: Median [15th, 85th percentile] preoperative LHR was 1.04 [1.01, 1.10]. Preoperative esophageal width > 3 cm and age > 68 years were most predictive of increased LHR. Increased LHR corresponded with decreases in longitudinal postoperative symptom relief and complete esophageal emptying, with a 4% difference in symptom relief and 20% difference in complete emptying, as LHR increased from 1.0 to 1.16. After adjusting for patient factors, including LHR, manometric subtype was less predictive of symptom relief, with estimated symptom relief occurring in 4% fewer patients with Type III achalasia, compared to Types I and II. Overall, LHR decreased following myotomy in patients with an initially tortuous esophagus., Conclusion: Length-to-height ratio was the only variable highly predictive of both longitudinal post-myotomy symptom relief and complete esophageal emptying, whereas manometric subtype was less predictive. These findings highlight the importance of tortuosity in the treatment of patients with achalasia, suggesting that inclusion of esophageal morphology in future iterations of achalasia classification is warranted., (© 2024. The Author(s).)