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Although gender-related disparities in intermediate-term outcomes have been reported after transcatheter aortic valve implantation (TAVI), disparate predictors of mortality in men and women who underwent TAVI have not been well studied. This prospective institutional registry study included 297 consecutive patients (153 men, 144 women) who underwent transfemoral TAVI from December 2015 to June 2018 at an academic tertiary medical center. Baseline and clinical characteristics, procedural data, and clinical outcomes at 1 year were recorded. Mortality rates at 1 year were 11.1% and 20.3% in women and men, respectively (p = 0.033). Risk-adjusted mortality was significantly higher in men who underwent TAVI than in women (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.24 to 4.87, p = 0.010). Gender-specific risk-adjusted predictors of 1-year mortality post-TAVI included the presence of atrial fibrillation (OR 4.20, 95% CI 1.31 to 13.46, p = 0.016) and peripheral artery disease (OR 4.64, 95% CI 1.04 to 20.71, p = 0.044) in women and presence of chronic obstructive pulmonary disease (OR 3.14, 95% CI 1.13 to 8.72, p = 0.029), higher serum creatinine (OR 1.57, 95% CI 1.15 to 2.15, p = 0.004), and lower body mass index (OR 0.88, 95% CI 0.80 to 0.97, p = 0.008) in men. In this prospective institutional registry of adults who underwent TAVI, risk-adjusted 1-year mortality is significantly lower in women, and disparate predictors of risk-adjusted 1-year mortality exist in men and women.

Individuals with clonal hematopoiesis of indeterminate potential (CHIP) is associated with a 2-4 fold increase in cardiovascular diseases (CVDs). While most studies focus on mutant blood cells, we propose that a better insight into the CHIP-CVD connection can be obtained by examining the genetic mutations in both the vascular endothelium and peripheral blood samples from the same patient. In this study, we examined somatic mutations by whole exome sequencing in paired blood and vascular samples from 4 patients with severe coronary artery disease who underwent coronary artery bypass graft surgery. We found that blood and endothelium can acquire the same mutations during aging and CHIP-associated mutations are not uncommon in vascular endothelium in patients with severe CVDs. Since vascular endothelial cells have critical roles in the regulation of cardiovascular function, mutant vascular endothelium offers an opportunity for further investigations to improve our diagnosis and management of individuals with CHIP.

Thoracic aortic aneurysms (TAA) are usually a silent disease that can prove fatal if complications (i.e., rupture or dissection) arise. Aortic diameter has been described as a major risk factor for TAA adverse outcomes or surgical intervention. Other comorbidities and importantly socioeconomic factors are less well-analyzed variables in large population studies. Using the New York State (NYS) Statewide Planning and Research Cooperative Systems (SPARCS) database, the purpose of this retrospective cohort study is to identify the risk factors associated with adverse outcomes in a patient population with newly diagnosed non-ruptured TAA between the time range of 2005-2018. &nbsp

In cytologic analysis of lung nodules, specimens classified as atypia cannot be definitively diagnosed as benign or malignant. Atypia patients are typically subject to additional procedures to obtain repeat samples, thus delaying diagnosis. We evaluate morphologic categories predictive of lung cancer in atypia patients. This retrospective study stratified patients evaluated for primary lung nodules based on cytologic diagnoses. Atypia patients were further stratified based on the most severe verbiage used to describe the atypical cytology. Logistic regressions and receiver operator characteristic curves were performed. Of 129 patients with cytologic atypia, 62.8% later had cytologically or histologically confirmed lung cancer and 37.2% had benign respiratory processes. Atypia severity significantly predicted final diagnosis even while controlling for pack years and modified Herder score (p = 0.012). Pack years, atypia severity, and modified Herder score predicted final diagnosis independently and while adjusting for covariates (all p < 0.001). This model generated a significantly improved area under the curve compared to pack years, atypia severity, and modified Herder score (all p < 0.001) alone. Patients with severe atypia may benefit from repeat sampling for cytologic confirmation within one month due to high likelihood of malignancy, while those with milder atypia may be followed clinically.

The changing surgical education landscape in surgical training pathways greatly diminished cardiac surgical knowledge, interest, and skills among general surgery trainees. To address this issue, our department developed a cardiac surgery simulation program.All simulation sessions lasted at least 2 hours and occurred during resident physician protected education time. Participants were postgraduate year 2 through 5 general surgery residents assisted by staff and led by cardiac surgery faculty. Five of the 6 sessions were porcine heart wet labs simulating coronary anastomoses, surgical aortic valve replacement, mitral valve repair and replacement, and left ventricular assist device implantation. The transcatheter aortic valve replacement session was designed as a video simulation and a manikin for wire manipulation and implantation. At the end of each lab, all participants were surveyed about their experiences.An average of 10 resident physicians participated in each session (range, 8-13), for a total of 120 simulation hours. One hundred percent of residents surveyed agreed that the labs improved knowledge and understanding of the disease process, improved understanding of cardiac surgical principles, and helped acquire skills for surgical residency and treatment. Factors that residents cited for increased attendance rate included protected education time, hands-on experience, and a high faculty-to-resident ratio.This program successfully demonstrates that cardiac surgery training and simulation can be integrated into general surgery residency programs, despite the lack of cardiac surgery requirements. Additional metrics for future study includes technical grades on resident physicians' performance to further assess the value of this program.

The impact of gender on management and early outcomes after transcatheter aortic valve implantation (TAVI) in the setting of newer generation transcatheter heart valves (THVs) is not well known. We evaluated gender-specific differences on clinical management and in-hospital outcomes in adults who underwent TAVI with newer generation THVs. The study population included 298 consecutive patients who underwent TAVI and received a newer generation THV (Sapien 3 [Edwards Lifesciences, Irvine, California] or Corevalve Evolut R or Evolut Pro [Medtronic, Minneapolis, Minnesota]) from December 2015 to June 2018 at an academic tertiary medical center. Of the 298 patients, 154 (52%) were men and 144 (48%) were women. Compared with men, women were older, had lower serum creatinine, higher left ventricular ejection fraction, and lower rates of multiple co-morbidities, including previous coronary artery bypass graft surgery, previous myocardial infarction, and atrial fibrillation. Women were noted to have smaller aortic annular area and perimeter and underwent implantation of smaller THVs than men. At the time of discharge, women were more frequently prescribed a P2Y12 inhibitor (primarily clopidogrel) and less frequently prescribed oral anticoagulation (namely warfarin). Hospital length of stay and in-hospital rates of mortality, disabling stroke, and pacemaker were similar in men and women. In conclusion, in this observational prospective study of adults who underwent TAVI with newer generation THVs, while gender-related disparities in clinical presentation and procedural management were observed, no significant difference in clinical outcomes were noted in men and women. Further studies examining gender-related differences in procedural and postprocedural care after TAVI in the contemporary era are warranted to better understand and optimize clinical outcomes in both men and women.

Background. The clinical impact of the distressed communities index (DCI), a composite measure of economic well-being based on the U.S. zip code, is becoming increasingly recognized. Ranging from 0 (prosperous) to 100 (distressed), DCI’s association with cardiovascular outcomes remains unknown. We aimed to study the association of the DCI with presentation and outcomes in adults with severe symptomatic aortic stenosis (AS) undergoing transcatheter aortic valve intervention (TAVR) in an affluent county in New York. Methods. The study population included 286 patients with severe symptomatic AS or degeneration of a bioprosthetic valve who underwent TAVR with a newer generation transcatheter heart valve (THV) from December 2015 to June 2018 at an academic tertiary medical center. DCI for each patient was derived from their primary residence zip code. Patients were classified into DCI deciles and then categorized into 4 groups. The primary and secondary outcomes of interest were 30-day, 1-year, and 3-year mortality, respectively. Results. Among 286 patients studied, 26%, 28%, 28%, and 18% were categorized into DCI groups 1–4, respectively (DCI 30: n = 52). Patients in group 4 were younger with worse kidney function compared to patients in groups 1 and 2. They also had smaller aortic annuli and were more likely to receive a smaller THV. No significant difference in hospital length of stay or distribution of in-hospital, 30-day, 1-year, and 3-year mortality was demonstrated. Conclusions. While the DCI was associated with differences in the clinical and anatomic profile, it was not associated with differences in clinical outcomes in this prospective observational study of adults undergoing TAVR suggesting that access to care is the likely discriminator.

This case illustrates that transfemoral transcatheter aortic valve replacement is safe and feasible in patients with bicuspid aortic stenosis with extremely large annulus and concomitant severe left ventricular dysfunction.

Consensus guidelines for prosthesis selection in infective endocarditis recommend bioprosthetic or mechanical valve replacement based on life expectancy and comorbidity. However, contemporary outcome data are limited to institution series.The outcomes of 3,447 patients identified from mandatory discharge databases in California and New York who had either primary isolated mitral (n = 1,603) or aortic (n = 1,844) valve replacement for active endocarditis between 1998 and 2010 were compared according to whether they received bioprosthetic (n = 1,673, 48.5%) or mechanical (n = 1,774, 51.5%) valves. Drug abusers were analyzed as a separate cohort. The primary outcome was endocarditis recurrence. Median follow-up time was 6.8 years (range, 0 to 12). Last follow-up for survival was December 31, 2015.Patients receiving bioprosthetic valves were older (60.4 ± 14.9 versus 53.4 ± 14.3 years, p0.001), with more comorbidity. There was no significant difference in 12-year survival with bioprosthetic versus mechanical valves after mitral (adjusted hazard ratio 1.14, 95% confidence interval [CI]: 0.98 to 1.34, p = 0.10) or aortic (adjusted hazard ratio 1.10, 95% CI: 0.93 to 1.29, p = 0.26) valve replacement. Bioprosthetic and mechanical valves were associated with similar recurrence rates at 12 years: 10.4% (95% CI: 8.0% to 13.1%) versus 8.8% (95% CI: 6.9% to 10.9%), adjusted Cox p = 0.79 after mitral replacement; and 9.4% (95% CI: 7.5% to 11.6%) versus 10.0% (95% CI: 8.0% to 12.4%), adjusted Cox p = 0.81 after aortic valve replacement.Bioprosthetic and mechanical valves are associated with similar survival and freedom from endocarditis recurrence. These data support guideline recommendations that patient factors guide prosthesis choice in infective endocarditis.

The association between Medicare Severity-Diagnosis Related Group (DRG) and 30-day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) has not been well studied. We aimed to evaluate the relationship between DRG and 30-day clinical outcomes in patients with severe

The association between chronic kidney disease (CKD) and outcomes following transcatheter aortic valve replacement (TAVR) in the setting of newer-generation transcatheter heart valves (THVs) is not well known. Accordingly, we sought to assess the impact of CKD severity on outcomes in adults undergoing TAVR with newer-generation THVs.The study population included 298 consecutive patients who underwent TAVR with a newer-generation THV (Sapien 3 [Edwards Lifesciences] or CoreValve Evolut R or Evolut Pro [Medtronic]) from December 2015 to June 2018 at an academic tertiary medical center. Patients were classified into three groups: group I, defined as creatinine clearance (CrCl) ≥60 mL/ min (n = 133); group II, defined as CrCl ≥30 mL/min and60 mL/min (n = 128); and group III, defined as CrCl30 mL/min (n = 37).Median length of stay was longer in groups II and III (2.0 days in group I vs 3.0 days in group II vs 4.0 days in group III; P.01). While rates of 30-day readmission were significantly higher in groups II and III compared with group I (14.5% in group I vs 26.6% in group II vs 37.1% in group III; P.01), rates of in-hospital and 30-day mortality and disabling stroke were similar. In multivariable analysis, CKD was independently associated with higher 30-day readmission rates (group II: odds ratio, 2.10; 95% confidence interval 1.02-4.32; group III: odds ratio, 3.52; 95% confidence interval, 1.40-8.87; group I: referent).In this prospective study of adults undergoing TAVR with newer-generation THVs, moderate and severe CKD was associated with a nearly 2-fold and 3-fold higher risk of 30-day readmission, respectively.

Background The optimal cerebral perfusion strategy during hypothermic circulatory arrest for acute type A aortic dissection repair is controversial. This study used a national clinical registry to evaluate cerebral protection strategies. Methods Using the Society of Thoracic Surgeons Adult Cardiac Surgical Database, study investigators identified 6387 patients with aortic dissection (mean age, 60.4 years, SD 13.5 years) who underwent total arch (n = 872; 13.7%) or ascending or hemiarch (n = 5515; 86.3%) replacement with circulatory arrest between 2014 and 2016 in the United States. Multivariable analysis adjusted for potential confounders, including demographics and comorbidity. Outcomes were compared according to the following: use of retrograde, antegrade, or no cerebral perfusion; nadir temperature; and duration of circulatory arrest. The primary end point was a composite of 30-day and in-hospital mortality or stroke. Results The rate of death or stroke was 25.5% (n = 1627). Antegrade cerebral perfusion was used in 46.2% (n = 2950) patients, retrograde cerebral perfusion was used in 22.6% (n = 1445), and no cerebral perfusion was used in 31.2% (n = 1992). In multivariable analysis, death or stroke risk increased with longer circulatory arrest duration (adds ratio [OR], 1.11 per 10-minute increment; 95% confidence interval [CI], 1.08 to 1.14). Multivariate analysis stratified by temperature showed improved outcomes with cerebral perfusion (antegrade or retrograde) and deep (OR, 0.86; 95% CI, 0.74 to 0.98), or moderate (OR, 0.78; 95% CI, 0.65 to 0.95) hypothermic circulatory arrest vs circulatory arrest without cerebral perfusion. There was a slight correlation between nadir temperature and the primary outcome. Conclusions Cerebral perfusion should be used during arch repair for aortic dissection because antegrade and retrograde cerebral perfusion strategies are associated with reduced death and stroke risk compared with hypothermic circulatory arrest without cerebral perfusion.

Incidental lung nodule algorithm depends on the patient’s risk factors as well as the nodule’s characteristics on imaging and change over time. Small (≤8 mm), unsuspicious nodules can be followed by serial CT scans. When the likelihood for cancer increases (bigger nodules, risk factors etc.), a PET/CT scan followed by tissue biopsy is warranted. If primary lung malignancy is confirmed, cancer staging is paramount and will dictate the treatment approach (resection for stage I or II and chemoradiation for advanced disease or poor surgical candidacy).

A 78-year-old man presented with severe symptomatic aortic stenosis and a heavily calcified, stenotic aortic valve. Given multiple comorbidities, the heart team agreed on a transcatheter approach via the left common carotid artery.

The impact of gender on early outcomes following transcatheter aortic valve replacement (TAVR) in the setting of contemporary valves is not well known. We aimed to evaluate gender-specific differences on 30-day outcomes in adults undergoing TAVR with contemporary valves. The study population

Medicare's Post-Acute Transfer (PACT) policy costs hospitals nationwide penalties following transcatheter aortic valve replacement. While discharging home without home services avoids PACT policy activation, its impact on 30-day outcomes following transcatheter aortic valve replacement (TAVR) is not

The impact of chronic renal disease on outcomes following transcatheter aortic valve replacement (TAVR) is not well known. Moreover, readmission rates following TAVR have not been adequately studied in the era of contemporary newer generation valves. We aimed to evaluate the impact of moderate and

Consensus guidelines recommend repair over replacement for the surgical treatment of active native mitral valve infective endocarditis. However, contemporary practice and long-term outcome data are limited.Multivariable Cox regression was used to compare outcomes of 1970 patients undergoing isolated primary mitral valve repair (n = 367, 19%) or replacement (n = 1603, 81%) for active infective endocarditis between 1998 and 2010 in New York and California states. The primary outcome was long-term survival. Secondary outcomes were recurrent endocarditis and mitral reoperation. Median follow-up time was 6.6 years (range 0-12), and last follow-up date was December 31, 2015.Mitral valve repair rates increased from 10.7% to 19.4% over the study period (P .001). Patients undergoing mitral repair were younger (55 ± 15 vs 57 ± 15 years, P = .005), less likely to have congestive heart failure (46.3% vs 57.1%, P .001), and less likely to have staphylococcal infections (21.3% vs 32.0%, P .001). Twelve-year survival was 68.8% (95% confidence interval [CI], 62.5%-74.3%) after mitral repair, versus 53.5% (95% CI, 50.6%-56.4%) after replacement (adjusted hazard ratio, 0.71; 95% CI, 0.57-0.88; P = .002). Mitral repair was associated with lower rate of recurrent endocarditis at 12 years than replacement (4.7% [95% CI, 2.8%-7.2%] vs 9.5% [95% CI, 8.0-11.1%]; P = .03), and similar rate of reoperation (9.1% [95% CI, 6.2%-12.8%] vs 8.6% [95% CI, 7.1%-10.4%]; P = .12).In active endocarditis, mitral valve repair is associated with better survival and lower risk of recurrent infection compared with valve replacement and should be the surgery of choice when feasible.

From the Mount Sinai Medical Center, New York, NY. Address reprint requests to Andrey Apinis, MD, Mount Sinai Medical Center, Department of Anesthesiology, 1 Gustave L. Levy Place, New York, NY 10029. E-mail: andrey.apinis@mountsinai.org © 2011 Elsevier Inc. All rights reserved. 1053-0770/2505-0031$36.00/0 doi:10.1053/j.jvca.2010.04.016

Acute type A aortic dissections are considered surgical emergencies because these patients are at risk for life-threatening complications. Patients who present with significant neurologic and other end-organ malperfusion may benefit from a more conservative approach. We present a patient with type A aortic dissection and concomitant mesenteric and limb ischemia.

Iliac vein rupture is a rare cause of retroperitoneal hemorrhage. It is occasionally lethal, with no clear precipitating factors. We report a case of spontaneous left common iliac vein rupture in a 56-year-old man with a history of deep vein thrombophlebitis (DVT). To date, 32 cases have been reported in the literature. The 32 existing cases and the case presented here were analyzed. A comparative review was performed for chief complaints, basic demographics, potential predisposing factors, treatment modalities, and outcomes. Possible etiological factors to explain this phenomenon were formulated. The patient presented with abdominal pain of 4 hr duration and a near-syncope episode. In the emergency room, he was found to be in hypovolemic shock that was responsive to crystalloids. An urgent exploratory laparotomy was performed for a suspected iliac artery rupture. An uncontrollable hemorrhage from a spontaneous posteromedial tear of the left common iliac vein resulted in intraoperative death. Interestingly, 85% of reported cases occurred in women with an overall average age of 60.6 +/- 13.4 years; 94% of cases were left-sided; 79% reported clinical or histological evidence of DVT or thrombophlebitis; 94% were treated operatively, with a survival rate of 71%. Only one reported case was treated conservatively, with success, and one reported case of endovascular repair resulted in significant morbidity. Iliac vein rupture is an uncommon diagnosis associated with trauma and even rarer when it is spontaneous. We report the thirty-third documented case in the literature since 1961. There is a clear predominance in females and on the left side and a probable association with thrombophlebitis. Our calculated operative success may be overestimated due to a biased literature reporting of favorable outcomes.

In their recent review of ablation options for atrial fibrillation, Pinho-Gomes et al. [1] omitted permanent pacemaker requirement as a complication of surgical ablation. In their series of 594 patients undergoing concomitant surgical ablation of atrial fibrillation, of whom 6.9% required permanent pacemakers postoperatively, Pecha et al. [2] identified biatrial lesion sets as a statistically significant risk factor for permanent pacemaker insertion after surgical ablation, confirming the findings of Soni et al. [3] in their series of 305 patients. We analysed 17 983 patients undergoing valve surgery with concomitant ablation identified from the Nationwide Inpatient Sample between 2002 and 2010. This administrative database is sponsored by the Agency for Healthcare Research and Quality, and contains information on all inpatient episodes in approximately one-fifth of US hospitals selected to provide a representative sample of national practice: the individual hospitals sampled vary each year. Pacemakers were implanted in 6.9% of patients undergoing valve surgery. After adjusting for baseline patient comorbidity, concomitant ablation procedure [odds ratio (OR) 1.31, 95% confidence interval (CI) 1.27–1.41] was one of the main independent predictors of permanent pacemaker implantation in patients undergoing valve surgery. In patients undergoing ablation, valve procedures associated with the greatest risk of permanent pacemaker requirement were mitral replacement (OR 1.37, 95% CI 1.2–1.67) and combined mitral replacement and tricuspid valve surgery (OR 1.79, 95% CI 1.69– 2.77) (isolated aortic valve replacement was used as the reference). Mitral repair was less likely to result in permanent pacemaker (OR 0.84, 95% CI 0.72–0.98), unless concomitant tricuspid surgery was undertaken (OR 1.79, 95% CI 1.37–2.33). These surgical predictors of permanent pacemaker requirement are consistent with data from a previous single-centre series [4], and the overall incidence of pacemaker insertion we observed is similar to that reported in an analysis of the Society of Thoracic Surgeons database [5]. The main limitation of the Nationwide Inpatient Sample in this context is that it does not provide information on the ablation lesion sets employed, or provide sufficient data to adjust for other potential confounding variables. However, this analysis indicates that patients undergoing concomitant surgical ablation at the time of valve surgery have a significantly increased risk of postoperative permanent pacemaker requirement in comparison with those who do not undergo concomitant ablation.