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Background: Conduction abnormalities requiring permanent pacemaker (PPM) implantation are common after tricuspid valve operations, although the incidence is variable. This study investigated contemporary rates of and risk factors for a PPM after tricuspid operations., Methods: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to identify patients with tricuspid repair or replacement from 2011 to 2020. Factors independently associated with the risk of a postoperative PPM during the index hospital admission were examined using multivariable logistic regression with a complete case approach. Annualized hospital and surgeon volumes were calculated., Results: We identified 71,937 patients undergoing tricuspid operations. Median patient age was 66 years (interquartile range, 53-74 years), 56% (n = 40,590) were women, and the median ejection fraction was 0.56 (interquartile range, 0.48-0.60). Tricuspid operations were concomitant in 87% (n = 62,457), elective in 62% (n = 44,393), and included repair in 86% (n = 61,720). Overall postoperative incidence of a PPM was 15% (n = 10,857); 13% (n = 8304) after repair and 25% (n = 2553) after replacement; and 4% (n = 174) for isolated tricuspid repair and 24% (n = 1248) for isolated tricuspid replacement. Multivariable analysis showed baseline characteristics, endocarditis, concomitant operations, longer cardiopulmonary bypass time, tricuspid replacement, and lower hospital and surgeon tricuspid operative volumes were independently associated with greater risk for a PPM. After adjustment, tricuspid replacement had 3.2-times greater PPM risk compared with tricuspid repair., Conclusions: Nationally, 15% of patients undergoing tricuspid operations required postoperative PPM implantation. PPM risk was increased with concomitant valve operations, tricuspid replacement, longer cardiopulmonary bypass time, and operations performed by less experienced surgeons and centers. Innovation is needed to decrease this significant morbidity., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2025 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Failure to rescue (FTR) is mortality after at least 1 postoperative complication. We investigated the impact of nighttime intensivist staffing and FTR after cardiac surgery., Methods: We included patients who underwent cardiac surgery to examine FTR, defined as mortality in those who experienced a Society of Thoracic Surgeons-defined major complication. Era 2 (July 2021-June 2023) and era 1 (July 2016-June 2021) were characterized by the presence and absence of nighttime intensivists staffing, respectively. Complications and FTR rates, daily intensive care unit (ICU) census, and relative value units (RVUs) were compared., Results: Among 5654 patients, 17% (284 of 1661) in era 2 had at least 1 complication vs 19% (769 of 3993) in era 1 (P = .057). Among patients with complications, FTR incidence was 8% (22 of 284) in era 2 vs 19% (145 of 769) in era 1 (P < .001). The daily average ICU census did not change (12.3 in era 2 vs 12.0 in era 1, P = .386). Comparing mean annual RVUs during the 2 fiscal years in era 2 (35,613 per year) with what would have been expected based on the last 2 fiscal years of era 1 (26,744 per year), a significant increase of +8870 per year was observed (95% CI, 3876-13,863, P = .028). Multivariable analyses found no difference in the risk of major complications comparing era 2 vs era 1 (odds ratio, 1.04; 95% CI, 0.89-1.23; P = .602), and a 59% reduction in FTR risk in era 2 vs era 1 (odds ratio, 0.41; 95% CI, 0.25-0.67; P < .001)., Conclusions: Nighttime ICU coverage reduced FTR rates in postcardiotomy patients while complication rates and ICU census remained stable. Furthermore, the increase in RVUs suggested an economically sustainable model., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2025 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Providing meaningful activity is a critical dimension of person-centered care for residents with dementia in all settings, including assisted living. Defined broadly as participation in physical, social, and leisure activities that provide meaning and value to the person and are tailored to individualized interests and preferences, meaningful activity has implications for well-being, mental health, cognition, and physical function. Assisted living residents with dementia would benefit from having more opportunities to engage in meaningful activity. There is a need to develop and assess practical tools to help assisted living staff evaluate preferences and identify opportunities to engage residents with dementia in meaningful activity. To address this need, we developed the Meaningful Engagement Assessment tool. Based on implementation of this tool with 31 residents in 2 assisted living communities, we provide a description of the feasibility and recommendations for strategies to facilitate the successful implementation of this tool in practice., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

Objective: Preoperative anemia is prevalent in cardiac surgery and independently associated with increased risk for short-term and long-term mortality. The purpose of this study was to examine the effect of preoperative hematocrit (Hct) on outcomes in cardiac surgical patients and whether the effect is comparable across levels of Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM)., Methods: The study consisted of adult, isolated coronary artery bypass grafting (CABG) or single-valve surgical patients in a statewide registry from 2011 to 2022 (N = 29,828). Regressions were used to assess effect of preoperative Hct on STS-defined major morbidity/mortality including the interaction of Hct and STS PROM as continuous variables., Results: Median age was 66 years (58-73 years), STS PROM was 1.02% (0.58%-1.99%), and preoperative Hct was 39.5% (35.8%-42.8%). The sample consisted of 78% isolated CABG (n = 23,261), 10% isolated mitral valve repair/replacement (n = 3119), 12% isolated aortic valve replacement (n = 3448), and 29% were female (n = 8646). Multivariable analyses found that greater Hct was associated with reduced risk of STS-defined morbidity/mortality (odds ratio, 0.96; P < .001). These effects for Hct persisted even after adjustment for intraoperative blood transfusion. The interaction of Hct and STS PROM was significant for morbidity/mortality (odds ratio, 1.01; P < .001). There was a stronger association between Hct levels and morbidity/mortality risk in the patients with the lowest STS risk compared with patients with the greatest STS risk., Conclusions: Patients with lower risk had a greater association between preoperative Hct and major morbidity and mortality compared with patients with greater risk. Preoperative anemia management is essential across all risk groups for improved outcomes., Competing Interests: Conflict of Interest Statement N.A. reported AtriCure consultant, Medtronic speaker, LivaNova consultant, VGS advisory board, CardioSight advisory board, and Left Atrial Appendage Occlusion LLC co-founder. N.B.H. reported Octapharma scientific advisory board. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Right ventricular (RV) donor-recipient sizing has been demonstrated to be a sensitive predictor for mortality after heart transplantation. We sought to understand the relationship between donor-recipient RV mass (RVM) ratio and pulmonary vascular resistance (PVR) on outcomes after heart transplantation., Methods: Adult heart transplant recipients from the United Network for Organ Sharing database were included (N = 42,594). The influence of RVM ratio and PVR on 1-year mortality was assessed by logistic regression after multivariable adjustment., Results: Among transplant recipients, median PVR was 2.4 Wood units (WU) (range, 1.7-3.3 WU) and median RVM ratio was 1.2 (1.0-1.3). Without considering PVR, RVM ratio was highly associated with postoperative dialysis (odds ratio [OR], 0.49; P < .001) and 1-year mortality (OR, 0.64; P < .001). Without considering RVM ratio, PVR was highly associated with 1-year mortality (OR, 1.05; P < .001), but not postoperative dialysis (OR, 0.98; P = .156). When considering both RVM ratio and PVR, the risk associated with each remained significant, but PVR did not modify the effect of RVM ratio on 1-year mortality (RVM ratio × PVR: OR, 0.99; P = .858). To maintain a consistent predicted 1-year mortality, RVM ratio would need to increase by 0.12 for each WU increase in PVR. Secondary analyses found that a 1 WU change in PVR was associated with an 11% increase in mortality risk in RVM ratio mismatched patients (RVM ratio < 1; P = .001), but only a 5% increase in RVM ratio matched patients (RVM ratio ≥ 1; P = .003)., Conclusions: RVM ratio and recipient PVR are independent predictors of 1-year mortality. Still, a larger RV mass may be utilized to mediate the effects of an elevated PVR., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The purpose of this manuscript is to describe the protocol for an Alzheimer's Association-funded cluster randomized trial that focuses on engaging assisted living residents with dementia in meaningful activity to help address their behavioral symptoms of distress using a theoretically based approach, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). The development of MAC-4-BSD was based on the Social Ecological Model and Social Cognitive Theory. The MAC-4-BSD intervention includes the following four steps: (1) Assessment of the assisted living physical environment and policies to facilitate meaningful activity; (2) Education of staff about implementation of meaningful activity; (3) Assessment of resident preferences and goals for meaningful activity; (4) Mentoring and motivating staff and residents to facilitate engagement in meaningful activity. The overall aim of this study will be to determine the feasibility and preliminary efficacy of implementing the MAC-4-BSD intervention and test whether it will improve residents' engagement in meaningful activity, behavioral symptoms of distress, and quality of life as well as the environment and policies to promote meaningful activity in assisted living., (© 2024 Wiley Periodicals LLC.)

Objectives: The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents' age, gender, comorbidities, and cognition. Understanding factors associated with engagement in meaningful activity can help to inform strategies for optimizing engagement among residents with dementia in assisted living., Method: This descriptive study used baseline data from a randomized controlled trial, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). Linear regression was used to examine factors associated with engagement in meaningful activity., Results: A total of 71 residents from 5 assisted living settings were included in the sample. Most participants were female ( n  = 52, 73%), White ( n  = 62, 87%), and mean age was 85 years old (SD = 8.2). Controlling for age, gender, comorbidities, and cognition, pain was significantly associated with engagement in meaningful activity (b= -2.09, p  < 0.05). There were no associations found between function and behavioral symptoms with engagement in meaningful activity., Conclusion: Findings from this study show that pain is a significant factor that is negatively associated with residents' engagement in meaningful activity. Ongoing research is needed to help improve pain management for residents with dementia in assisted living and support their engagement in meaningful activity.

Objectives: To describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care's antipsychotic reduction initiative (ARI)., Methods: Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses., Results: There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = -0.0003, p <.001; post-ARI b = -0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = -0.0026, p <.001), licensed practical nurse hours (b = -0.0019, p <.001), facility chain membership (b = -0.0013, p <.01), and health inspection ratings (b = -0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant., Conclusions: Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff., Clinical Implications: Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period.

Background: In the absence of high-quality evidence, there is a need for guidelines and multidisciplinary consensus recommendations on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The purpose of this expert consensus conference was to evaluate the existing evidence regarding the diagnosis and management of BIA-ALCL caused by textured implants. This article aims to provide evidence-based recommendations regarding the management and prevention of BIA-ALCL., Methods: A comprehensive search was conducted in the MEDLINE, Cochrane Library, and Embase databases, and supplemented by manual searches of relevant English-language articles and "related articles" sections. Studies focusing on breast surgery and lymphoma associated with breast implants were included for analysis. Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons using a Delphi consensus method., Results: A total of 840 articles published between January of 2011 and January of 2023 were initially identified and screened. The full text of 188 articles was assessed. An additional 43 articles were excluded for focus, and 145 articles were included in the synthesis of results, with 105 of them being case reports or case series. The analysis encompassed a comprehensive examination of the selected articles to determine the incidence, risk factors, clinical presentation, diagnostic approaches, and treatment modalities related to BIA-ALCL., Conclusions: Plastic surgeons should be aware of the elevated risks by implant surface type, implement appropriate patient surveillance, and follow the recommendations outlined in this statement to ensure patient safety and optimize outcomes. Ongoing research on the pathogenesis, genetic drivers, and preventative and prophylactic measures for BIA-ALCL is crucial for improving patient care., Clinical Question/level of Evidence: Risk, V., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons.)

Purpose: Skin pigmentation influences peripheral oxygen saturation (SpO 2 ) compared to arterial saturation of oxygen (SaO 2 ). Occult hypoxemia (SaO 2  ≤ 88% with SpO 2  ≥ 92%) is associated with increased in-hospital mortality in venovenous-extracorporeal membrane oxygenation (VV-ECMO) patients. We hypothesized VV-ECMO cannulation, in addition to race/ethnicity, accentuates the SpO 2 -SaO 2 discrepancy due to significant hemolysis., Methods: Adults (≥ 18 years) supported with VV-ECMO with concurrently measured SpO 2 and SaO 2 measurements from over 500 centers in the Extracorporeal Life Support Organization Registry (1/2018-5/2023) were included. Multivariable logistic regressions were performed to examine whether race/ethnicity was associated with occult hypoxemia in pre-ECMO and on-ECMO SpO 2 -SaO 2 calculations., Results: Of 13,171 VV-ECMO patients, there were 7772 (59%) White, 2114 (16%) Hispanic, 1777 (14%) Black, and 1508 (11%) Asian patients. The frequency of on-ECMO occult hypoxemia was 2.0% (N = 233). Occult hypoxemia was more common in Black and Hispanic patients versus White patients (3.1% versus 1.7%, P < 0.001 and 2.5% versus 1.7%, P = 0.025, respectively). In multivariable logistic regression, Black patients were at higher risk of pre-ECMO occult hypoxemia versus White patients (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.18-2.02, P = 0.001). For on-ECMO occult hypoxemia, Black patients (aOR = 1.79, 95% CI = 1.16-2.75, P = 0.008) and Hispanic patients (aOR = 1.71, 95% CI = 1.15-2.55, P = 0.008) had higher risk versus White patients. Higher pump flow rates (aOR = 1.29, 95% CI = 1.08-1.55, P = 0.005) and on-ECMO 24-h lactate (aOR = 1.06, 95% CI = 1.03-1.10, P < 0.001) significantly increased the risk of on-ECMO occult hypoxemia., Conclusion: SaO 2 should be carefully monitored if using SpO 2 during ECMO support for Black and Hispanic patients especially for those with high pump flow and lactate values at risk for occult hypoxemia., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Prior investigations assessing the impact of race/ethnicity on outcomes after mitral valve (MV) surgery have reported conflicting findings. This analysis aimed to examine the association between race/ethnicity and operative presentation and outcomes of patients undergoing MV and tricuspid valve (TV) surgery., Methods: We retrospectively analyzed 5984 patients (2730 female, median age 63 y) who underwent MV (n = 4,534, 76%), TV (n = 474, 8%) or both MV and TV (n = 976, 16%) surgery in a statewide collaborative from 2012 to 2021. The influence of race/ethnicity on preoperative characteristics, MV and TV repair rates, and postoperative outcomes was assessed for White (n = 4,244, 71%), Black (n = 1,271, 21%), Hispanic (n = 144, 2%), Asian (n = 171, 3%), and mixed/other race (n = 154, 3%) patients., Results: Black patients, compared to White patients, had higher Society of Thoracic Surgeons predicted risk of morbidity/mortality (24.5% versus 13.1%; P < 0.001) and more comorbid conditions. Compared to White patients, Black and Hispanic patients were less likely to undergo an elective procedure (White 71%, Black 55%, Hispanic 58%; P < 0.001). Degenerative MV disease was more prevalent in White patients (White 62%, Black 41%, Hispanic 43%, Asian 51%, mixed/other 45%; P < 0.05), while rheumatic disease was more prevalent in non-White patients (Asian 28%, Hispanic 26%, mixed/other 25%, Black 17%, White 10%;P < 0.05). After multivariable adjustment, repair rates and adverse postoperative outcomes, including mortality, did not differ by racial/ethnic group., Conclusions: Patient race/ethnicity is associated with a higher burden of comorbidities at operative presentation and MV disease etiology. Strategies to improve early detection of valvular heart disease and timely referral for surgery may improve outcomes., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The redundant leaflet tissue and annular pathology of Barlow disease can make surgical repair challenging. We examined perioperative and late outcomes of a large cohort of patients with Barlow disease undergoing surgical repair., Methods: Patients included in this analysis underwent mitral valve repair from 01/2004-11/2021 by a single surgeon., Results: Of 2798 patients undergoing mitral valve operations, 46% (N.=1292) had degenerative pathology and 7% (N.=184) had Barlow disease. Of the 179 Barlow patients, median age at surgery was 62 (51-70) years; 64% were male (115/179). Rates of non-resectional cordal repair and resectional repair were 86% (154/179) and 14% (25/179). Among patients undergoing non-resectional repair, the median number of cordal pairs inserted on the anterior and posterior leaflets was 2 (2-3) and 4 (3-4). Incidence of return to bypass for systolic anterior motion of the mitral valve, perioperative death, stroke, and renal failure was 2% (4/179), 1% (2/179), 0% (0/179), and 0% (0/179). Rates of clinical and echocardiographic follow-up were 93% (165/177) and 89% (157/177). Median time to latest postoperative clinical and echocardiographic follow-up was 2.4 (0.8-6.1) and 2.1 (0.6-4.7) years. Mitral regurgitation grade at latest follow-up or time of repair failure was none/trace, mild, mild to moderate, and severe in 63% (98/157), 26% (41/157), 8% (12/157), and 4% (6/157); five of six patients with severe MR underwent reoperation. Since 2011 97% (139/144) of patients underwent cordal repair without resection., Conclusions: Non-resectional artificial cordal repair is safe and feasible in almost all patients with Barlow valves and is associated with excellent mid-term results.

Objective: Atrial fibrillation (AF), if left untreated, is associated with increased intermediate and long-term morbidity/mortality. Surgical treatment for AF is lacking standardization in patient selection and lesion set, despite clear support from multi-society guidelines. The aim of this study was to analyze a statewide cardiac surgery registry to establish whether or not there is an association between center volume and type of index procedure with performance of surgical ablation (SA) for AF, the lesion set chosen, and ablation technology used., Methods: Adult, first-time, nonemergency patients with preoperative AF between 2014 and 2022 excluding standalone SA procedures from a statewide registry of Society of Thoracic Surgeons data were included (N = 4320). AF treatment variability by hospital volume (ordered from smallest to largest) and surgery type were examined with χ 2 analyses. Hospital-level Spearman correlations compared hospital volume with proportion of AF patients treated with SA., Results: Overall, 37% of patients with AF were ablated at the time of surgery (63% of mitral procedures, 26% of non-mitrals) and 15% had left atrial appendage management only. There was a significant temporal trend of increasing performance of SA for AF over time (Cochran-Armitage = 27.8; P < .001). Hospital cardiac surgery volume did not correlate with the proportion of AF patients treated with SA (r s  = 0.19; P = .603) with a rate of SA below the state average for academic centers. Of cases with SA (n = 1582), only 43% had a biatrial lesion set. Procedures that involved mitral surgery were more likely to include a biatrial lesion set (χ 2  = 392.3; P < .001) for both paroxysmal and persistent AF. Similarly, ablation technology use was variable by type of concomitant operation (χ 2  = 219.0; P < .001) such that radiofrequency energy was more likely to be used in non-mitral procedures., Conclusions: These results indicate an increase in adoption of SA for AF over time. No association between greater hospital volume or academic status and performance of SA for AF was established. Similar to national data, the type of index procedure remains the most consistent factor in the decision to perform SA with a disconnect between AF pathophysiology and decision making on the type of SA performed. This analysis demonstrates a gap between evidence-based guidelines and real-world practice, highlighting an opportunity to confer the benefits of concomitant SA to more patients., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures., Methods: The Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status., Results: A total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ 2  = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726)., Conclusions: In a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Importance: Skin pigmentation influences peripheral oxygen saturation (SpO 2 ) measured by pulse oximetry compared to the arterial saturation of oxygen (SaO 2 ) measured via arterial blood gas analysis. However, data on SpO 2 -SaO 2 discrepancy are limited in venovenous-extracorporeal membrane oxygenation (VV-ECMO) patients., Objective: To determine whether there is racial/ethnical discrepancy between SpO 2 and SaO 2 in patients receiving VV-ECMO. We hypothesized VV-ECMO cannulation, in addition to race/ethnicity, accentuates the SpO 2 -SaO 2 discrepancy due to significant hemolysis., Design: Retrospective cohort study of the Extracorporeal Life Support Organization Registry from 1/2018-5/2023., Setting: International, multicenter registry study including over 500 ECMO centers., Participants: Adults (≥ 18 years) supported with VV-ECMO with concurrently measured SpO 2 and SaO 2 measurements., Exposure: Race/ethnicity and ECMO cannulation., Main Outcomes and Measures: Occult hypoxemia (SaO 2 ≤ 88% with SpO 2 ≥ 92%) was our primary outcome. Multivariable logistic regressions were performed to examine whether race/ethnicity was associated with occult hypoxemia in pre-ECMO and on-ECMO SpO 2 -SaO 2 calculations. Covariates included age, sex, temporary mechanical circulatory support, pre-vasopressors, and pre-inotropes for pre-ECMO analysis, plus single-lumen versus double-lumen cannulation, hemolysis, hyperbilirubinemia, ECMO pump flow rate, and on-ECMO 24h lactate for on-ECMO analysis., Results: Of 13,171 VV-ECMO patients (median age = 48.6 years, 66% male), there were 7,772 (59%) White, 2,114 (16%) Hispanic, 1,777 (14%) Black, and 1,508 (11%) Asian patients. The frequency of on-ECMO occult hypoxemia was 2.0% ( N = 233). Occult hypoxemia was more common in Black and Hispanic versus White patients (3.1% versus 1.7%, P < 0.001 and 2.5% versus 1.7%, P = 0.025, respectively).In multivariable logistic regression, Black patients were at higher risk of pre-ECMO occult hypoxemia versus White patients (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.18-2.02, P = 0.001). For on-ECMO occult hypoxemia, Black patients (aOR = 1.79, 95%CI = 1.16-2.75, P = 0.008) and Hispanic patients (aOR = 1.71, 95%CI = 1.15-2.55, P = 0.008) had higher risk versus White patients. Furthermore, higher pump flow rate (aOR = 1.29, 95%CI = 1.08-1.55, P = 0.005) and higher on-ECMO 24h lactate (aOR = 1.06, 95%CI = 1.03-1.10, P < 0.001) significantly increased the risk of on-ECMO occult hypoxemia., Conclusions and Relevance: Hispanic and Black VV-ECMO patients experienced occult hypoxemia more than White patients. SaO 2 should be carefully monitored during ECMO support for Black and Hispanic patients especially for those with high pump flow and lactate values at risk for occult hypoxemia., Competing Interests: Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). Dr. Tonna is the Chair of the Registry Committee of the Extracorporeal Life Support Organization (ELSO). Dr. Brodie receives research support from and consults for LivaNova. He has been on the medical advisory boards for Abiomed, Xenios, Medtronic, Inspira and Cellenkos. He is the President-elect of the Extracorporeal Life Support Organization (ELSO) and the Chair of the Executive Committee of the International ECMO Network (ECMONet), and he writes for UpToDate. Dr. Lorusso is a consultant for Medtronic, LivaNova, Getinge and ASbiomed, and Member of the Medical Advisory Board of Eurosets and Xenios. He is the ELSO Research Committee Chair, and Honorary Secretary of EuroELSO. The authors do not have any additional conflicts of interest to declare. SPK is supported by NHLBI (5K08HL14332). SMC is supported by NHLBI (1K23HL157610).Disclosures: The authors have nothing to disclose

Background: Despite supportive evidence and guidelines, the use of multiple arterial grafts (MAGs) in coronary artery bypass grafting remains low. We sought to determine surgeon perception of personal MAG use and compare this with actual MAG use., Methods: We conducted a statewide surgeon survey of MAG use, presence of a hospital MAG protocol, and barriers for MAG use, with a response rate of 78% (n = 25). Surgeon survey responses were compared with actual Society of Thoracic Surgeons patient data from January 1, 2017, to December 31, 2020 using χ 2 or Fisher's exact tests., Results: Of 5299 patients who had first-time, nonemergent, isolated coronary artery bypass grafting (≥2 grafts) by responding surgeons, 16% received MAG (n = 825). MAG use in patients whose surgeons self-designated as "routine" MAG users was 21% vs 7% for "nonroutine" users. Surgeons with a hospital protocol for MAG use utilized MAG more often (18% vs 14%, P = .001). Surgeons who were unconvinced by the data on the benefits of MAGs used MAGs in 11% vs 22% in surgeons who were convinced. MAG use increased over time, particularly from before to after the survey (13.1% vs 30.5%, P < .001)., Conclusions: Although MAG use increased over time, barriers to routine use remain. In surgeons who reported routine use, only 21% of their patients received MAGs. Hospital protocols, education, and increased awareness may reduce barriers to use and encourage evidence-based clinical practice., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population., Methods: This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated., Results: Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p  < 0.01), emergency department (19.6% vs. 10.7%, p  < 0.01), and different NH (1.5% vs. 0.4%, p  < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use., Conclusions: Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.

Objective: Implantation of an appropriately sized donor heart is critical for optimal outcomes after heart transplantation. Although predicted heart mass has recently gained consideration, there remains a need for improved granularity in size matching, particularly among small donor hearts. We sought to determine if indexed donor cardiac output is a sensitive metric to assess the adequacy of a donor heart for a given recipient., Methods: A retrospective analysis was performed (2003-2021) in isolated orthotopic heart transplant recipients from the United Network for Organ Sharing database. Donor cardiac output was divided by recipient body surface area to compute cardiac index (donor cardiac index). Predicted heart mass ratio was computed as donor/recipient predicted heart mass. The primary outcome was mortality 1 year after transplant., Results: Among transplant recipients, median donor cardiac output was 7.3 (5.8-9.0) liters per minute and donor cardiac index was 3.7 (3.0-4.6) liters per minute/m 2 . Predicted heart mass ratio was 1.01 (0.91-1.13). After multivariable adjustment, higher donor cardiac index was associated with lower 1-year mortality risk (odds ratio, 0.92, P  = .042). Recipients with predicted heart mass ratio less than 0.80 (n = 255) had a lower median donor cardiac index than those with a predicted heart mass ratio of 0.80 or greater (3.2 vs 3.7, P  < .001). As predicted, heart mass ratio became smaller and the association between donor cardiac index and 1-year mortality became progressively stronger., Conclusions: Higher donor cardiac index was associated with a lower probability of 1-year mortality among patients undergoing heart transplantation and served to further quantify mortality risk among those with a small predicted heart mass ratio. Donor cardiac index appears to be an effective tool for size matching and may serve as an adjunctive strategy among small donor hearts with a low predicted heart mass ratio., (© 2023 The Authors.)

We aimed to describe practice patterns and outcomes in patients with extracorporeal membrane oxygenation (ECMO) support throughout the coronavirus 2019 (COVID-19) pandemic, with the hypothesis that mortality would improve as we accumulated knowledge and experience. We included 48 patients supported on veno-venous ECMO (VV-ECMO) at a single institution between April 2020 and December 2021. Patients were categorized into three waves based on cannulation date, corresponding to the wild-type (wave 1), alpha (wave 2), and delta (wave 3) variants. One hundred percent of patients in waves 2 and 3 received glucocorticoids, compared with 29% in wave 1 ( p < 0.01), and the majority received remdesivir (84% and 92% in waves 2 and 3, vs . 35% in wave 1; p < 0.01). Duration of pre-ECMO noninvasive ventilation was longer in waves 2 and 3 (mean 8.8 days and 3.9 days, vs . 0.7 days in wave 1; p < 0.01), as was time to cannulation (mean 17.2 and 14.6 days vs . 8.8 days in wave 1; p < 0.01) and ECMO duration (mean 55.7 days and 43.0 days vs . 28.4 days in wave 1; p = 0.02). Mortality in wave 1 was 35%, compared with 63% and 75% in waves 2 and 3 ( p = 0.05). These results suggest an increased prevalence of medically refractory disease and rising mortality in later variants of COVID-19., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2023.)

Objective: Coronary artery bypass grafting is associated with significant interhospital variability in charges. Drivers of hospital charge variability remain elusive. We identified modifiable factors associated with statewide interhospital variability in hospital charges for coronary artery bypass grafting., Methods: Charge data were used as a surrogate for cost. Society of Thoracic Surgeons data from Maryland institutions and charge data from the Maryland Health Care Commission were linked to characterize interhospital charge variability for coronary artery bypass grafting. Multivariable linear regression was used to identify perioperative factors independently related to coronary artery bypass grafting charges. Of the factors independently associated with charges, we analyzed which factors varied between hospitals., Results: A total of 10,337 patients underwent isolated coronary artery bypass grafting at 9 Maryland hospitals from 2012 to 2016, of whom 7532 patients were available for analyses. Mean normalized charges for isolated coronary artery bypass grafting varied significantly among hospitals, ranging from $30,000 to $57,000 (P < .001). Longer preoperative length of stay, operating room time, and major postoperative morbidity including stroke, renal failure, prolonged ventilation, reoperation, and deep sternal wound infection were associated with greater hospital charges. Incidence of major postoperative events, except stroke and deep sternal wound infection, was variable between hospitals. In a univariate linear regression model, patient risk profile only accounted for approximately 10% of statistical variance in charges., Conclusions: There is significant charge variability for coronary artery bypass grafting among hospitals within the same state. By targeting variation in preoperative length of stay, operating room time, postoperative renal failure, prolonged ventilation, and reoperation, cardiac surgery programs can realize cost savings while improving quality of care for this resource-intense patient population., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure in the world and up to one-third of patients are transfused red blood cells (RBCs). RBC transfusion may increase the risk for health care-associated infection (HAI) after CABG, but previous studies have shown conflicting results and many did not establish exposure temporality. Our objective was to explore whether intraoperative RBC transfusion is associated with increased odds of postoperative HAI. We hypothesized that intraoperative RBC transfusion would be associated with increased odds of postoperative HAI., Methods: We performed an observational cohort study of isolated CABG patients in the Society of Thoracic Surgeons adult cardiac surgery database from July 1, 2017, to June 30, 2019. The exposure was intraoperative RBC transfusion modeled as 0, 1, 2, 3, or 4+ units. The authors focused on intraoperative RBC transfusion as a risk factor, because it has a definite temporal relationship before postoperative HAI. The study's primary outcome was a composite HAI variable that included sepsis, pneumonia, and surgical site infection (both deep and superficial). Mixed-effects modeling, which controlled for hospital as a clustering variable, was used to explore the relationship between intraoperative RBC transfusion and postoperative HAI., Results: Among 362,954 CABG patients from 1076 hospitals included in our analysis, 59,578 patients (16.4%) received intraoperative RBCs and 116,186 (32.0%) received either intraoperative or postoperative RBCs. Risk-adjusted odds ratios for HAI in patients who received 1, 2, 3, and 4+ intraoperative RBCs were 1.11 (95% confidence interval [CI], 1.03-1.20; P = .005), 1.13 (95% CI, 1.05-1.21; P = .001), 1.15 (95% CI, 1.04-1.27; P = .008), and 1.14 (95% CI, 1.02-1.27; P = .02) compared to patients who received no RBCs., Conclusions: Intraoperative RBC transfusion is associated with a small increase in odds of HAI in CABG patients. Future studies should explore whether reductions in RBC transfusion can also reduce HAIs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)

Background: Patients presenting with acute coronary syndrome are administered a P2Y 12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice., Methods: We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared., Results: There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% ( P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients., Conclusions: There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks., Competing Interests: Conflicts of Interest: See Disclosures at the end of article., (Copyright © 2022 International Anesthesia Research Society.)

Background: There is an established relationship between the degree of mitral regurgitation (MR) and prognosis. Quantitation of MR severity guides therapeutic approaches. Inconsistent definitions and categorization of MR severity in clinical studies limit meaningful comparisons among trials and compromise development of an effective evidence base. The purpose of this study was to quantify heterogeneity in grading systems for MR severity in the contemporary literature., Methods: This was a systematic review of randomized controlled trials and propensity score-adjusted clinical studies of mitral valve interventions (surgical or percutaneous). A total of 35 articles from 2015 to 2020 were included (15 randomized controlled trials and 20 propensity score-adjusted clinical studies)., Results: There were 22 studies that reported MR severity in numeric categories, either values from the historical "plus" system or numeric MR grades, whereas 9 studies reported MR severity using text-only descriptive categories. Among the studies that used numeric categories, 2+ MR was defined as moderate in 64% of studies, mild in 27%, and mild-moderate in 9%, and 3+ MR was defined as moderate in 14%, moderate-severe in 52%, and severe in 14%., Conclusions: There was substantial variability in MR severity definition and reporting in contemporary clinical studies of mitral valve interventions. We recommend that the historical plus numeric grading system be abandoned and that inclusion and outcome criteria in MR clinical trials be based on US and European guideline-recommended categories as none or trace, mild, moderate, and severe. Adoption of these simple recommendations will improve the consistency and quality of MR clinical trial design and reporting., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to present a rigorous method to analyse the intraoperative echocardiographic images from the novel mitral translocation procedure, which assesses the changes in mitral structure and function and compares this data to a control group of patients who have no mitral regurgitation (MR)., Methods: Transoesophageal echocardiography was post-processed using dedicated 3D software. Ten patients with normal mitral valves (MV) undergoing non-mitral cardiac surgery served as controls. Mitral coaptation area, mid-leaflet coaptation length and mitral annular circumference were measured in 3D., Results: Twenty-three consecutive patients with severe secondary MR underwent MV translocation. All patients had none/trace MR post-translocation. The mean coaptation surface area increased from 63 to 427 mm2 (P < 0.001) and coaptation length increased from 1.0 to 10.5 mm (P < 0.001). The control group coaptation surface area (136 mm2) and length (2.5 mm) were greater than pre-translocation (P = 0.019; P < 0.001) and less than post-translocation (P < 0.001; P < 0.001). 3D mitral annular circumference in the translocation group decreased 15% (130-110 mm) (P < 0.001). Post-translocation, the mean gradient was 2(2-3) mmHg with the diastolic mitral orifice area of 3.4 ± 0.3 cm2 by planimetry and 3.5 ± 0.3 cm2 by pressure half-time. The coaptation to septum distance remained unchanged (P = 0.305) without systolic anterior leaflet motion., Conclusions: This echocardiographic analysis method demonstrates that MV translocation abolishes secondary MR, increases coaptation area and length and produces acceptable diastolic function. This method of analysis should allow precise structural and quantitative assessment of the durability of the repair in future long-term follow-up., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The COVID-19 pandemic necessitated a drastic increase in the use of telemedicine. There is little information about the effectiveness of telemedicine in cardiac surgery. We examined clinical outcomes and patient satisfaction among patients who had in-person versus telemedicine preoperative appointments in a subspecialized mitral valve surgical practice., Methods: We retrospectively reviewed all patients who had elective mitral valve operations between January 2019 and February 2021. Patients were categorized into 2 groups based on the format of the preoperative appointment (telemedicine or in-person). Preoperative characteristics and clinical outcomes were compared between the two groups. All patients who had a telemedicine appointment were sent an online survey to assess their satisfaction with the process., Results: Among 286 patients analyzed, 197 (69%) had in-person preoperative evaluations and 89 (31%) had telemedicine evaluations. The in-person and telemedicine groups had similar preoperative and operative characteristics. Outcomes did not differ between the 2 groups, including ventilation time (3.7 vs. 4.1 h, p = .399), total length of stay (5 vs. 5 days, p = .949), 30-day mortality (0% vs. 1%, p = .311), and readmissions within 30 days (13% vs. 8%, p = .197). Among patients who completed the survey, 91% were "satisfied" or "very satisfied" with the telemedicine preoperative appointment., Conclusion: Patients who had telemedicine preoperative appointments before mitral valve operations during the COVID-19 pandemic had similarly excellent clinical outcomes to patients who had in-person preoperative appointments before the pandemic. Patients had relatively high levels of satisfaction with telemedicine and almost half preferred telemedicine for future visits., (© 2022 Wiley Periodicals LLC.)

Optimal translocation patch width for functional mitral regurgitation (FMR) treatment was evaluated in an air-filled ex vivo system. FMR was created in 19 isolated swine hearts by annular dilation and papillary muscle displacement. Frustum-shaped pericardial patches of varying widths (Group 1 = 0.5 cm; Group 2 = 1.0 cm; Group 3 = 1.5 cm) were implanted and imaged via a 3D-structured light scanner. Median leaflet coaptation decreased (P < 0.001) from 5.5 ± 2.0 mm at baseline to 2.4 ± 1.3 mm following FMR creation. Translocation repair increased coaptation length over FMR levels by 2.2 mm in Group 1 (P < 0.001), 4.6 mm in Group 2 (P < 0.001), and 4.7 mm in Group 3 (P < 0.001). After repair, no significant differences were found between groups for annular height, circularity index, tenting height, tenting area, and non-coapting surface area. The supranormal coaptation and minimal valve geometric changes support using a 1.0- or 1.5-cm translocation patch for FMR treatment. Implantation of a 1.0-cm or 1.5-cm circumferential pericardial patch (mitral valve translocation) increases leaflet coaptation length without significantly altering valve geometry., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Enhanced Recovery After Surgery (ERAS) programs have demonstrated improved outcomes in noncardiac surgery. More recently, ERAS has been applied to cardiac surgery with promising results. We have implemented cardiac ERAS at our community-based program, aiming to improve all phases of care, and now report our early results., Methods: We retrospectively analyzed 73 consecutive patients treated with ERAS care compared with 74 patients treated before implementing ERAS. Our ERAS program consisted of 6 perioperative care bundles including enhanced patient education, shortened preoperative fasting period and oral carbohydrate load, postoperative nausea prophylaxis, multimodal opioid-sparing analgesia, early extubation, and early mobilization., Results: ERAS patients required significantly less opioids captured as total morphine milligram equivalents (MME) (median 35.0 vs 75.3; P < .001), less nausea as determined by fewer total ondansetron rescue doses (median 0 vs 0.5; P = .011), and less lightheadedness (P = .028) compared with pre-ERAS patients. Postoperative mobility was significantly better (postoperative day 4: 95% vs 81%; P = .013) and postoperative length of stay was lower for ERAS care but did not reach statistical significance (median 4 days vs 5 days; P = .06). There was no difference in pain or glucose control or in early extubation., Conclusions: Cardiac ERAS significantly decreased opioid use, nausea, and lightheadedness and improved functional outcome for cardiac surgical patients in a community hospital., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Theoretical studies demonstrate that controlled addition of noise can enhance the amount of information transmitted by a cochlear implant (CI). The present study is a proof-of-principle for whether stochastic facilitation can improve the ability of CI users to categorize speech sounds. Analogue vowels were presented to CI users through a single electrode with independent noise on multiple electrodes. Noise improved vowel categorization, particularly in terms of an increase in information conveyed by the first and second formant. Noise, however, did not significantly improve vowel recognition: the miscategorizations were just more consistent, giving the potential to improve with experience.

Background: The association between blood transfusion and adverse outcome is documented in cardiac surgery. However, the incremental significance of each unit transfused, whether red blood cell (RBC) or non-RBC, is uncertain. This study examined the relationship of patient outcomes with the type and number of blood product units transfused., Methods: Statewide data from 24 082 adult cardiac surgery patients were included. The relationship with blood transfusion was assessed for morbidity and 30-day mortality using total number of RBC and non-RBC units transfused, specific type of non-RBC units, and different combinations of transfusion (only RBC, only non-RBC, RBC + non-RBC). Multivariable logistic regressions examined these associations., Results: Median age was 66 years (30% female patients), and 51% of patients received a transfusion (31%-66% across hospitals). Risk-adjusted analyses found each blood product unit was associated with 9%, 7%, and 4% greater odds for 30-day mortality, major morbidity, and minor morbidity, respectively (all P < .001). Odds for 30-day mortality were 13% greater with each RBC unit (P < .001) and 6% greater for each non-RBC unit (P < .001). Each unit of fresh frozen plasma (P < .001) and platelets (P < .001) increased the odds for 30-day mortality, but no effect was found for cryoprecipitate (P = .725). Odds for 30-day mortality were lower for non-RBC-only (odds ratio, 0.52; P = .030) and greater for RBC + non-RBC (odds ratio, 2.98; P < .001) compared with RBC-only transfusion., Conclusions: Independent of center variability on transfusion methods, each additional unit transfused was associated with increased odds for complications, with RBC transfusion carrying greater risk compared with non-RBC. Comprehensive evidence-based clinical approaches and coordination are needed to guide each blood transfusion event after cardiac surgery., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Functional (secondary) mitral regurgitation (FMR) results from altered geometry of the mitral valve apparatus. Repair with restrictive mitral annuloplasty is associated with high rates of recurrent mitral regurgitation (MR). We developed a novel operative repair for FMR that translocates the intact mitral valve towards the apex., Methods: The mitral valve was detached circumferentially and translocated into the ventricle with a frustum-shaped glutaraldehyde-treated autologous pericardial patch. Clinical and echocardiographic follow-up was performed., Results: Fifteen consecutive patients with FMR (mean age, 59 years; 67% female) had mitral valve translocation between 2018 and 2020. Preoperative mean ejection fraction, left ventricular end-diastolic dimension, and systolic pulmonary artery pressure were 40% ± 11%, 59 ± 8 mm, and 49 ± 21 mm Hg, respectively; 33% had atrial fibrillation. Cardiomyopathy was ischemic in 4 and nonischemic in 11. Concomitant procedures included tricuspid valve operation (n = 8), coronary artery bypass grafting (n = 4), and atrial fibrillation ablation (n = 5). Post bypass transesophageal echocardiogram demonstrated none/trace MR in all patients and mean gradient of 3 mm Hg (interquartile range, 2-4 mm Hg). Mean leaflet extent of coaptation was 14 ± 2 mm (range, 11-17 mm). There was no postoperative mortality, stroke, or renal failure. Predismissal echocardiography showed none/trace MR in 14 patients and mild MR in 1. One patient underwent successful late rerepair of a suture line leak. Twelve patients were alive at latest follow-up and MR at 1 and 6 months was mild or less in all patients with mean leaflet extent of coaptation of 14 ± 2 mm (range, 12-16 mm) at 6 months., Conclusions: Mitral valve translocation creates a large surface of coaptation and effectively corrects FMR. Further study is needed to demonstrate the long-term durability and clinical utility of this operation., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Social inequities have many health effects; one of these is a potential relationship to sleep disturbances. Socioeconomic status (SES) is an important factor that contributes to social inequities. SES is a marker of living conditions and habits that influence health by way of different processes, including stress-related mechanisms. However, a systematic review of the relationship between SES and objectively measured sleep parameters has not been conducted. Therefore, a systematic review and meta-analysis were performed to examine the relationship between SES and sleep parameters measured with actigraphy in the general population. Nineteen articles were identified and included from a keyword search in Medline/PubMed, Web of Science, and SCOPUS, following PRISMA guidelines. For an article to be included, it had to have a measure of SES and also, an actigraphy-based measure of sleep. For, included studies, qualitative and quantitative data were extracted, and study quality was assessed with The National Institute of Health's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Bivariate correlations were extracted and entered into a meta-analysis, along with a qualitative review of articles. These analyses revealed that SES was associated with sleep parameters in the predicted direction, with lower SES associated with worse sleep parameters. Specifically, lower SES was associated with lower total sleep time, longer sleep latency, greater sleep fragmentation, and higher variability in sleep onset and sleep latency. Higher education, higher perceived economic well-being, and higher income were significantly associated with improved sleep efficiency and longer sleep duration. For the 19 articles included, 10 were rated as fair or poor in study quality. Thus, higher quality studies in this area are needed. This meta-analysis and systematic review demonstrated that social inequities of sleep can be measured objectively, opening the path to the development and integration of methodologies combining actigraphy with current subjective measures for utilization in clinical practice., (Copyright © 2021 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level., Design: This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)]., Setting and Participants: Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment., Measures: Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use., Results: The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites., Conclusions and Implications: This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment., (Copyright © 2020 AMDA — The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Understanding satisfaction with assisted living (AL) from the residents' perspective is essential for creating supportive environments that are targeted toward the needs and desires of residents. Few measures have been tested to evaluate residents' satisfaction with AL. This study tested the reliability and validity of the Resident Satisfaction Index (RSI) in a sample of 501 AL residents. Based on Rasch analysis, there was support for item reliability and construct validity. Differential item functional (DIF) analysis was done to examine differences in item responses by age, gender, and cognition. Significant and substantive differences were identified for five items by gender, one item by cognition, and no differences were found by age group. Findings suggest the RSI is a reliable and valid measure to assess residents' satisfaction with AL and can be used to guide administrators and clinicians in making changes in these settings to increase residents' satisfaction.

Objective: This study examined the learning curve for transseptal puncture (TSP) during transcatheter edge-to-edge mitral valve repair (TEER) performed by a dedicated mitral valve structural heart team. Effective TSP is mandatory for TEER but can be time-consuming and associated with complications including pericardial effusion and cardiac tamponade., Methods: TSP was performed on 107 consecutive patients (76 ± 1 years, 52% male) undergoing TEER between 2014 and 2019. TSP was performed by each structural heart team member (1 cardiologist, 2 cardiac surgeons) on a rotating case-by-case basis. No team member had prior independent TSP experience. Data collected included total procedure time, TSP time (time elapsed between procedure start and septal crossing), and number of TSP attempts before successful puncture. Cumulative sum (CUSUM) of deviations from the mean across sequential cases were used to examine learning curves., Results: Median total procedure time was 107 min, and the median TSP time was 14 min. Greater case number was significantly associated with both lower TSP time ( r s = -0.22, P = 0.022) and lower total procedure time ( r s = -0.29, P = 0.003). The majority of patients required only 1 TSP attempt (79%). There was a significant quadratic relationship between case number and the CUSUM for TSP time, with the learning curve peaking at 49 cases., Conclusions: TSP for TEER has a substantial learning curve, requiring >50 cases to achieve acceptable efficiency. Even once proficiency is demonstrated, TSP remains a time-consuming component of TEER. Improvements in transseptal access technology may significantly decrease the time needed to master TSP and may improve the safety and precision of the procedure.

Objective: To determine whether the changing cardiac landscape has affected traditional cardiothoracic surgery (CTS) resident case volume, particularly cardiac case volume., Methods: The Accreditation Council for Graduate Medical Education (ACGME) case logs for traditional CTS residents from 2016 to 2019 were reviewed. Using linear and nonlinear regression, trends in the annual volume and proportion of CTS operations were examined., Results: Overall, the average number of total and category-specific CTS resident cases have increased from 2016 to 2019. However, in general, the proportion of thoracic surgery cases has been increasing, and the proportion of cardiac surgery cases has been decreasing. In particular, the proportion of coronary atherosclerosis (-0.2546 per 100 cases/year; P < .001) and valvular heart disease (-0.319 per 100 cases/year; P < .001) procedures demonstrated the greatest downward trends. The average operative experience for residents has increased (28.8 cases/resident/year; P < .001), but cardiac track residents (22.24 cases/resident/year; P < .001) have had a smaller increase than thoracic track residents (35.04 cases/resident/year; P < .001). Nevertheless, cardiac track residents experienced an increase in their average proportion of cardiac cases (0.176 per 100 cases/year; P < .001) compared with average (-0.263 per 100 cases/year; P < .001) and thoracic track (-0.978 per 100 cases/year; P < .001) CTS residents, indicating specialization of the tracks., Conclusions: The overall CTS resident operative experience has increased over the last several years, with cardiac cases increasing more slowly than thoracic cases. The analysis reveals that cardiac operative volume has been asymmetrically allocated to cardiac track residents, indicating a greater specialization of the tracks. Annual evaluation of CTS resident case volume will provide essential insight into the field., (Copyright © 2020 The American Association for Thoracic Surgery. All rights reserved.)

Objective: There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons., Methods: Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year., Results: Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I 2 = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I 2 = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios., Conclusions: In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient's aortic valve disease.

The assisted living (AL) environment plays an important role in supporting residents' satisfaction and helping them to age in place. The AL environment is multidimensional and has many interrelated components including staffing (e.g. direct care workers, nursing, activity staff), services provided (e.g. medical, mental health, pharmacy), amenities offered at the setting (e.g. beauty salon, library, exercise facilities), and the physical environment. Evidence suggests that aspects of the AL environment can enhance or detract from the physical function, well-being, social engagement, and behavioral outcomes among residents. The purpose of this study was to develop and test a multidimensional AL environment measurement model that includes indicators of staffing, services, amenities, and the physical environment. Baseline data was used from a study testing the Dissemination and Implementation of Function Focused Care in AL. A total of 54 AL facilities across three states were included in the sample. Settings ranged in size from 31 to 164 beds with an average size of 82.2 (SD=26.2) beds and the majority were for profit facilities (n=41, 74.5%). Structural equation modeling was used to test the proposed model. Results showed that the model fit the data (χ 2 /df=1.861, p<.05; CFI=.858, RMSEA=.126). Having a comprehensive AL environment measurement model will advance future research that explores the impact of the environment on resident outcomes. Findings from this study will inform interventions and programs designed to modify AL environments to optimize residents' satisfaction with AL., Competing Interests: Conflict of interest: The authors have no financial or personal conflicts with this paper.

Interprofessional education (IPE) is critical for ensuring that students are prepared to collaborate with team members across disciplines once they enter clinical practice; particularly, in the complex care of the geriatric population. This qualitative study explored the experiences of interdisciplinary students in a clinical based IPE experience at a senior housing residence. Reflective journals were examined from students ( n  = 23) in nursing, social work, pharmacy, and medicine participating in an IPE program. Four core themes emerged in the analysis: exposure to geriatrics, IPE advantages for students, IPE advantages for older adults, and IPE challenges. Findings from this study confirmed advantages of IPE in a real-world clinical setting in terms of students learning the value and scope of practice of interdisciplinary team members. The exposure to geriatrics helped students to gain an in-depth understanding of issues affecting older adults in the community and increase professional confidence in their future clinical practice.

Background: Several studies have established morbidity associated with bleeding after cardiac surgery. Although reoperation has been implicated as the marker for this morbidity, there remains limited understanding regarding relative morbidities of reoperation and substantial transfusion., Methods: The Society of Thoracic Surgeons (STS) Maryland Adult Cardiac Surgery Database (July 2011-September 2018) was reviewed (N = 23,240). Substantial transfusion was defined as requiring greater than the reoperation group median red blood cells (5 units) and non-red blood cells (4 units). Patients were stratified into 4 subgroups: group 1, no reoperation without substantial transfusion (n = 22,365); group 2, reoperation without substantial transfusion (n = 351); group 3, no reoperation with substantial transfusion (n = 350); and group 4, reoperation with substantial transfusion (n = 167). Operative morbidity and mortality were compared., Results: Reoperation patients were older with a higher STS predicted risk of mortality (1.8% vs 1.2%, P < .001). Multivariable analysis demonstrated that group 4 increased the odds of renal failure (odds ratio [OR] 7.36, P < .001), stroke (OR 3.24, P = .002), and operative mortality (OR 8.68, P < .001) compared with group 1. Both group 2 and group 3 increased the odds of mortality and renal failure compared with group 1. However, group 3 had greater risk for renal failure (OR 3.48, P < .001) and mortality (OR 2.91, P < .001) than group 2., Conclusions: Although reoperation for bleeding is associated with morbidity after cardiac surgery, substantial transfusion without reoperation appears to increase morbidity compared with a limited-transfusion reoperative approach. Better timing for reoperation and guided transfusion approaches may mitigate morbidity compared with substantial transfusion alone., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Racial disparities persist in health care. Our study objective was to evaluate racial disparity in cardiac surgery in Maryland., Methods: A statewide database was used to identify patients. Demographics, comorbidities, and predicted risk of death were compared between races. Crude mortality and incidence of complications were compared between groups, as were risk-adjusted odds for mortality and major morbidity or mortality., Results: The study included 23,094 patients. Most patients were white (75.8%), followed by African American (16.3%), Asian (3.8%), and other races (4.1%). African Americans had a higher preoperative risk for mortality based on The Society of Thoracic Surgeons predictive models compared with white patients (3.0% vs 2.3%, P < .001). African Americans also had higher prevalence of diabetes mellitus, hypertension, peripheral vascular disease, and cerebral vascular disease than white patients. After adjustment for preoperative risk, there was no difference in 30-day mortality between African Americans (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.99-1.59), Asians (OR, 1.22; 95% CI, 0.75-1.97), and other races (OR, 1.18; 95% CI, 0.74-1.89) compared with whites. African Americans had lower risk-adjusted odds of major morbidity or mortality compared with whites (OR, 0.83; 95% CI, 0.75-0.93)., Conclusions: African American cardiac surgical patients have the highest preoperative risk in Maryland. Patients appeared to receive excellent cardiac surgical care, regardless of race, as risk-adjusted mortality did not differ between groups, and African American patients had lower risk-adjusted odds of major morbidity or mortality than white patients. Future interventions in Maryland should be aimed at reducing preoperative risk disparity in cardiac surgical patients., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In 2014 Maryland began a global budget revenue (GBR) program where hospitals were assigned a global budget for each year. We hypothesized that this program would be associated with changes in coronary artery bypass grafting (CABG) patient risk profile, reductions in potentially preventable complications (PPCs) and 30-day hospital readmissions, and low annual per patient charge growth., Methods: Patients having isolated CABG surgery in Maryland between fiscal years 2013 and 2017 were included. Patient characteristics, admission all-payer refined severity of illness, PPCs, 30-day hospital readmissions, and per patient hospital charges were compared between years. The impact of Maryland's GBR program on PPCs and 30-day hospital readmissions was evaluated using interrupted time series analysis., Results: During the study period 11,070 patients had CABG surgery. The percentage of patients with major or extreme severity of illness at admission differed significantly between years (34.6% in 2013 vs 46.1% in 2017, P < .001). There was a significant reduction in mean PPC incidence of -22.8% (95% confidence interval, -29.8% to -15.8%) after GBR implementation but no significant reduction in 30-day hospital readmissions (-2.7%; 95% confidence interval, -6.0% to 0.6%). Without adjusting for inflation the annual per patient charge growth remained between -1.4% and 2.6% from 2013 to 2017., Conclusions: Maryland's GBR program was associated with significant PPC reductions, minimal charge growth, and no significant change in 30-day hospital readmissions during its first 14 fiscal quarters. These findings suggest that Maryland's GBR program achieved some but not all of its predefined goals in CABG patients., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Resectional and artificial cordal repair techniques are effective strategies for degenerative mitral valve (MV) repair. However, resectional repair requires a tailored approach using various techniques, whereas cordal repair offers a simpler, easily reproducible repair. The approach described in this study approach has evolved from resectional to cordal over time, and outcomes are compared between the eras., Methods: Clinical and echocardiographic outcomes of all patients undergoing MV repair for degenerative mitral regurgitation (MR) from January 2004 to September 2017 were reviewed. Patients were stratified by era: from January 2004 to June 2011 (era 1; n = 405), resectional techniques were used in 62% and artificial cordal techniques were used in 38%. From July 2011 to September 2017 (era 2; n = 438), artificial cordal repair was used in 98% of patients. The primary outcome was repair failure, defined as greater than moderate MR or MV reoperation., Results: Of 847 patients with degenerative MR, successful repair was achieved in 843 patients (99.5% repair rate). Leaflet prolapse was posterior in 66%, anterior in 8%, and bileaflet in 26%. Cardiopulmonary bypass time and cross-clamp times were shorter in era 2 (CPB: 109 [IQR, 92-128] minutes vs 97 [IQR, 76-121] minutes; P < .001; cross-clamp: 88 [IQR, 73-106] minutes vs. 79 [IQR, 61-99] minutes; P < .001). Predismissal echocardiography demonstrated no MR or trace MR in 95%, mild MR in 4.7%, and moderate MR in 0.3% of patients. Operative mortality was similar in the eras (0.5% vs 0.5%; P > .999). The rates of 5-year freedom from repair failure (95.1% vs 95.5%; P = .707), stroke (96.8% vs 95.3%; P = .538), and endocarditis (99.3% vs 99.7%; P = .604) were similar between the eras., Conclusions: Artificial cordal repair for all patients with degenerative MR simplifies MV repair and yields equivalent, excellent outcomes compared with a tailored resectional approach., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)