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Mary Ann Clark,1 Francis G Duhay,2 Ann K Thompson,2 Michelle J Keyes,3 Lars G Svensson,4 Robert O Bonow,5 Benjamin T Stockwell,3 David J Cohen61The Neocure Group LLC, Washington, DC, 2Edwards Lifesciences Corporation, Irvine, CA, 3The Burgess Group LLC, Alexandria, VA, 4Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH, 5Center for Cardiovascular Innovation, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 6Saint Luke's Mid America Heart Institute, Kansas City, MO, USABackground: Aortic valve replacement (AVR) is the standard of care for patients with severe, symptomatic aortic stenosis who are suitable surgical candidates, benefiting both non-high-risk and high-risk patients. The purpose of this study was to report long-term medical resource use and costs for patients following AVR and validate our assumption that high-risk patients have worse outcomes and are more costly than non-high-risk patients in this population.Methods: Patients with aortic stenosis who underwent AVR were identified in the 2003 Medicare 5% Standard Analytic Files and tracked over 5 years to measure clinical outcomes, medical resource use, and costs. An approximation to the logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) based on administrative data was used to assess surgical risk, with a computed logistic EuroSCORE > 20% considered high-risk.Results: We identified 1474 patients with aortic stenosis who underwent AVR, of whom 1222 (82.9%) were non-high-risk and 252 (17.1%) were high-risk. Among those who were non-high-risk, the mean age was 73.3 years, 464 (38.2%) were women, and the mean logistic EuroSCORE was 7%, whereas in those who were high-risk, the mean age was 77.6 years, 134 (52.8%) were women, and the mean logistic EuroSCORE was 37%. All-cause mortality was 33.2% for non-high-risk and 66.7% for high-risk patients at 5 years. Over this time period, non-high-risk patients experienced an average of 3.9 inpatient hospitalizations and total costs of $106,277 per patient versus 4.7 hospitalizations and total costs of $144,183 for high-risk patients.Conclusion: Among elderly patients undergoing AVR, long-term mortality and costs are substantially greater for high-risk than for non-high-risk individuals. These findings indicate that further research is needed to understand whether newer approaches to aortic valve replacement such as transcatheter AVR may be a lower cost, clinically valuable alternative.Keywords: aortic valve, replacement, health economics

OBJECTIVES: Evaluate aortic root preserving/sparing procedures for various pathologies associated with ascending aortic aneurysms, including aortic valve regurgitation. METHODS: From the end of 1990 through end of 2004, 388 patients had aortic root preserving procedures (reimplantation 72, remodeling 77, tailoring 239) +/- leaflet repair. Preoperatively, in-house grade aortic regurgitation was 1(+) in 58, 2(+) in 110, 3(+) in 101, and 4(+) in 66. Concurrent leaflet repairs were done in 197 (50.8%, Cabrol/Trusler commissure stitch 158, leaflet plication 36, supracommissure stitch 42, leaflet resection and repair 16, perforation repair 18, and debridement 11). Additional procedures included arch repair in 227 (58%), coronary bypass in 83 (21.4%), elephant trunk in 33 (8.5%), and minimally invasive approach in 30 (7.7%). Pathologies included dissection in 140 (36%; 86 acute), Marfan syndrome in 39 (10%), bicuspid valve in 78 (20%), and degenerative aneurysm in 142 (36.6%). The CLASS (Commissure, Leaflet, Annulus, Sinuses, Sinotubular) evaluation schema is described that is used for selecting either reimplantation, remodeling, or tailoring of the aortic root according to underlying pathology. RESULTS: Hospital survival was 97.4% (378/388) and stroke occurred in 4.6% (18/388, four permanent, [1%]). On postoperative echocardiography, patients had either no (0) or 1(+) regurgitation (1(+)= 98);13 (3.4%) had 2(+). Three patients (1%) required reoperation for aortic valve failure before discharge (two tailoring, one remodeling). CONCLUSIONS: Excellent early results can be achieved by aortic root preserving procedures and concurrent aortic valve leaflet repairs when appropriately selected for a diverse class of pathologies. [ABSTRACT FROM AUTHOR]

Purpose: To examine the efficacy of a staged approach for the treatment of thoracoabdominal aneurysms, with open visceral revascularization followed by aortic endografting, in selected patients not considered candidates for conventional surgical repair. Methods: A retrospective review was conducted of 13 consecutive patients (8 women; mean age 64 years, range 33-77) who underwent visceral bypass followed by endovascular thoracoabdominal stent-graft implantation since 1999. Three patients presented with symptomatic aneurysms and 2 with rupture. Two patients had connective tissue disorders. All patients were deemed unfit for conventional thoracoabdominal repair due to comorbid conditions. The procedures were tailored to the pathology and specific patient anatomical situation: 5 aortic dissections with aneurysmal degeneration and 8 aneurysms (5 Crawford type II, 2 type III, and 1 type IV). Results: The patients underwent retrograde visceral bypass (11 iliovisceral and 2 infrarenal aortic to visceral artery) followed by endovascular aortic relining with Zenith TX2 devices (n=7), homemade endografts (n=5), or a Talent thoracic endograft (n=1). Six patients required either a proximal or distal direct aortic repair (2 infrarenal reconstructions, 3 arch elephant trunk grafts, and 1 ascending aortic repair), while 3 patients also underwent left carotid-subclavian bypass grafting. Two patients developed paraplegia (1 following a ruptured aneurysm), and 2 patients had transient paraparetic events. Two patients had acute renal failure requiring short-term dialysis. Three patients died within 30 days; 2 late aneurysm-related deaths were noted. Three patients developed endoleaks during follow-up. Mean lengths of stay were 13 days (7-30) for the visceral bypass and 12 (3-25) for the endovascular stent-graft. In addition, remaining procedures in 8 patients required a mean of 7 days (0-14) in hospital. Conclusion: Staged endovascular and open procedures are feasible for thoracoabdominal aneurysms in patients at prohibitive risk for open thoracoabdominal reconstruction. However, this approach still carries a significant risk of perioperative mortality and morbidity. The potential for less invasive alternatives should be investigated. [ABSTRACT FROM AUTHOR]

During the early 1980s, the rate of paralysis after aortic surgery was as high as 41% in patients for the most complex thoracoabdominal aortic operations. After comparing human and chacma baboon (papio ursinus) spinal cord vascular anatomy, an animal model was established to study the pathophysiology of aortic cross-clamping and the aetiology of the paralysis. Techniques, including motor evoked responses for monitoring spinal cord function, were developed that were tried in humans and later culminated in prospective and randomized studies. These established that the following were protective: combining cerebrospinal fluid with intrathecal papaverine; cooling systemically to moderate or profound hypothermia; minimizing intercostal ischaemia time; using a sequential segmental repair approach; re-attaching all patent and segmental intercostal arteries below T8 for descending thoracic aortic repair and from T6 to L2 for thoracoabdominal repairs; continuing cerebrospinal fluid drainage for at least two days and maintaining patients hypertensive after surgery. The net result has been that, in two of our recent series, the risk of permanent paralysis has been reduced to between 3.1% and 3.8%. [ABSTRACT FROM AUTHOR]

Objective: As bioprosthetic aortic valve replacement (AVR) extends to younger cohorts, tissue durability is of paramount importance. We report 7-year outcomes from an AVR bioprosthesis utilizing novel tissue., Methods: This was an international investigational device exemption trial for novel AVR with annual follow-up and a subset re-consented at 5 years for extended 10-year follow-up. Safety end points and echocardiographic measurements were adjudicated by an independent clinical events committee and by a dedicated core laboratory, respectively., Results: Between January 2013 and March 2016, 689 patients underwent AVR with the study valve. Mean age was 66.9 ± 11.6 years, Society of Thoracic Surgeons risk score was 2.0% ± 1.8%, and 74.3% of patients were New York Heart Association functional class II and III. Five-year follow-up was completed by 512 patients, and 225 re-consented for extended follow-up. Follow-up duration was 5.3 ± 2.2 years (3665.6 patient-years), and 194 and 195 patients completed 6- and 7-year follow-ups, respectively. One-, 5-, and 7-year freedom from all-cause mortality was 97.7%, 89.4%, and 85.4%, respectively. Freedom from structural valve deterioration at 7 years was 99.3%. At 7 years, effective orifice area and mean gradients were 1.82 ± 0.57 cm 2 (n = 153), and 9.4 ± 4.5 mm Hg (n = 157), respectively. At 7 years, predominantly none (96.8% [152 out of 157]) or trivial/trace (2.5% [4 out of 157]) paravalvular regurgitation and none (84.7% [133 out of 157]) or trivial/trace (11.5% [18 out of 157]) transvalvular regurgitation were observed., Conclusions: We report the longest surgical AVR follow-up with novel tissue in an investigational device exemption trial utilizing an independent clinical events committee and an echocardiography core laboratory. This tissue demonstrates excellent outcomes through 7 years and is the benchmark for future surgical and transcatheter prostheses., Competing Interests: Conflict of Interest Statement Dr Beaver is on the Data Safety Monitoring Board at Nexxus, a study site investigator and consultant for Edwards Lifesciences, and a study site principal investigator and consultant for Atricure. Dr Thourani is an advisor/research for Edwards Lifesciences. Dr Pibarot has received institutional funding from Edwards Lifesciences, Medtronic, Pi-Cardia, and Cardiac Success for echocardiography core laboratory analyses and research studies in the field of interventional and pharmacologic treatment of valvular heart diseases, for which he received no personal compensation. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling 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 Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The study objective was to identify the effects of surgeon experience and age, in the context of cumulative institutional experience, on risk-adjusted hospital mortality after cardiac reoperations., Methods: From 1951 to 2020, 36 surgeons performed 160,338 cardiac operations, including 32,871 reoperations. Hospital death was modeled using a novel tree-bagged, generalized varying-coefficient method with 6 variables reflecting cumulative surgeon and institutional experience up to each cardiac operation: (1) number of total and (2) reoperative cardiac operations performed by a surgeon, (3) cumulative institutional number of total and (4) reoperative cardiac operations, (5) year of surgery, and (6) surgeon age at each operation. These were adjusted for 46 patient characteristics and surgical components., Results: There were 1470 hospital deaths after cardiac reoperations (4.5%). At the institutional level, hospital death decreased exponentially and became less variable, leveling at 1.2% after approximately 14,000 cardiac reoperations. For all surgeons as a group, hospital death decreased rapidly over the first 750 reoperations and then gradually decreased with increasing experience to less than 1% after approximately 4000 reoperations. Surgeon age up to 75 years was associated with ever-decreasing hospital death., Conclusions: Surgeon age and experience have been implicated in adverse surgical outcomes, particularly after complex cardiac operations, with young surgeons being novices and older surgeons having declining ability. However, at Cleveland Clinic, outcomes of cardiac reoperations improved with increasing primary surgeon experience, without any suggestion to mid-70s of an age cutoff. Patients were protected by the cumulative background of institutional experience that created a culture of safety and teamwork that mitigated adverse events after cardiac surgery., 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 © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the durability of mitral valve repair with complete ring or flexible band annuloplasty in patients with atrial functional mitral regurgitation due to atrial fibrillation and identify risk factors associated with postoperative mitral regurgitation recurrence., Methods: From 1/1/2000-1/1/2023, 194 adults with history of atrial fibrillation underwent mitral valve repair with annuloplasty alone for moderate/severe atrial functional mitral regurgitation. Exclusion criteria were prior cardiac surgery, additional repair techniques, ejection fraction<45%, ischemic heart disease, aortic valve disease, mitral annular calcification, and concomitant procedures other than surgical ablation or tricuspid repair/replacement. Durability of annuloplasty was assessed using longitudinal analysis of postoperative echo data., Results: Complete ring annuloplasty was performed in 126/194(65%) patients; partial ring(posterior band) was chosen in 68/194(35%). Concomitantly, 64%(124/194) of patients underwent tricuspid valve surgery and 89%(173/194) an atrial fibrillation procedure, including biatrial Cox-Maze III/IV lesion set in 88%(152/173) and pulmonary vein isolation in 12%(21/173). All patients were discharged with no/trace mitral regurgitation. Freedom from moderate/severe mitral regurgitation after repair with annuloplasty alone was 89% at 10 years, and no significant differences were noted between complete vs. partial ring annuloplasty(early P=0.41, late P=0.92). Forty-eight percent of patients developed atrial fibrillation 3 or more months after surgery, and presence of postoperative atrial fibrillation was not associated with higher likelihood of recurrence of mitral regurgitation(P=0.15). Freedom from mitral reintervention was 96% at 10 years(Graphical Abstract)., Conclusions: In appropriate patients with atrial functional mitral regurgitation, long-term durability of annuloplasty is excellent with complete ring and posterior band annuloplasty techniques., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Valve-sparing aortic root replacement for proximal aortic dilation with aortic regurgitation is associated with excellent outcomes. Modified aortic reimplantation entails reducing the anulus size to the expected size for sex and body surface area and creating neosinuses to preserve the aortic valve. We present our mid- and late-term outcomes with the modified technique, including a single-surgeon's experience over the past 2 decades., Methods: From January 2002 to January 2024, 528 patients underwent modified aortic reimplantation for aortic aneurysm or dilation; 491 were included in this study. End points included time-related mortality and postoperative morbidities, including aortic valve reintervention and longitudinal aortic regurgitation grade., Results: There were no operative deaths. Survival at 30 days, 1 year, and 15 years were 100%, 99.6%, and 87%, respectively. Postoperative stroke occurred in 4 patients (0.81%) and reoperation for bleeding in 7 (1.4%). Moderate or severe aortic valve regurgitation was seen in 6.2% and 10% of patients at 1 and 10 years, respectively. Aortic valve mean gradients were 7.0 and 7.5 mm Hg at 1 and 10 years, respectively. Freedom from reintervention on the aortic valve was 99.9%, 99%, and 95% at 30 days, 1 year, and 15 years, respectively., Conclusions: Modified aortic reimplantation technique is a reliable and reproducible technique with excellent mid- and long-term outcomes in survival and freedom from reintervention. The results advocate for modified reimplantation in patients with enlarged aortic roots, especially in younger patients with connective tissue disorder., 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.)

Objective: To demonstrate applying American Association for Thoracic Surgery Quality Gateway (AQG) outcomes models to a Surgeon Case Study of quality assurance in adult cardiac surgery., Methods: The case study includes 6,989 cardiac and thoracic aorta operations performed in adults at Cleveland Clinic by one surgeon from 2001 to 2023. AQG models were used to predict expected probabilities for operative mortality and major morbidity, and to compare hospital outcomes, surgery type, risk profile, and individual risk-factor levels using virtual (digital) twin causal inference. These models were based on postoperative procedural outcomes after 52,792 cardiac operations performed in 19 hospitals of 3 high-performing hospital systems with overall hospital mortality of 2.0%, analyzed by advanced machine learning for rare events., Results: For individual surgeons, their patients, hospitals, and hospital systems, the Surgeon Case Study demonstrated that AQG provides expected outcomes across the entire spectrum of cardiac surgery, from single-component primary operations to complex multi-component reoperations. Actionable opportunities for quality improvement based on virtual twins is illustrated for patients, surgeons, hospitals, risk profile groups, operations, and risk factors vis-à-vis other hospitals., Conclusions: Using minimal data collection and models developed using advanced machine learning, this case study shows that probabilities can be generated for operative mortality and major morbidity after virtually all adult cardiac operations. It demonstrates the utility of 21st century causal inference (virtual [digital] twin) tools for assessing quality for surgeons asking "How am I doing?" their patients asking "What are my chances?" and the profession asking "How can we get better?", (Copyright © 2024. Published by Elsevier Inc.)

Objective: To investigate outcomes after aortic root allograft reoperation, identify risk factors for morbidity and mortality, and describe practice evolution since publication of our 2006 allograft reoperation study., Methods: From January 1987 to July 2020, 602 patients underwent 632 allograft-related reoperations at Cleveland Clinic: 144 before 2006 (early era, which suggested radical explant was superior to aortic-valve-replacement-within-allograft [AVR-only]), and 488 from 2006 to present (recent era). Indications for reoperation were structural valve deterioration in 502 (79%), infective endocarditis in 90 (14%), and nonstructural valve deterioration/noninfective endocarditis in 40 (6.3%). Reoperative techniques included radical allograft explant in 372 (59%), AVR-only in 248 (39%), and allograft preservation in 12 (1.9%). Perioperative events and survival were assessed among indications, techniques, and eras., Results: Operative mortality by indication was 2.2% (n = 11) for structural valve deterioration, 7.8% (n = 7) in those with infective endocarditis, and 7.5% (n = 3) for nonstructural valve deterioration/noninfective endocarditis, and by surgical approach 2.4% (n = 9) after radical explant, 4.0% (n = 10) for AVR-only, and 17% (n = 2) for allograft preservation. Operative adverse events occurred in 4.9% (n = 18) of radical explants and 2.8% (n = 7) of AVR-only procedures (P = .2). Patients undergoing radical explants received larger valves than those undergoing AVR-only (median, 25 vs 23 mm)., Conclusions: Aortic root allograft reoperations present a technical challenge but can be performed with low mortality and morbidity. Radical explant offers outcomes similar to AVR-only while allowing for implant of larger prostheses. Increasing experience with allograft reoperations has permitted excellent outcomes; thus, risk of reoperation should not dissuade surgeons from using allografts for invasive aortic valve infective endocarditis and other indications., (Copyright © 2023. Published by Elsevier Inc.)

Objective: Surgical registries play a crucial role in clinical knowledge discovery, hospital quality assurance, and quality improvement. However, maintaining a surgical registry requires significant monetary and human resources given the wide gamut of information abstracted from medical records ranging from patient co-morbidities to procedural details to post-operative outcomes. Although natural language processing (NLP) methods such as pretrained language models (PLMs) have promised automation of this process, there are yet substantial barriers to implementation. In particular, constant shifts in both underlying data and required registry content are hurdles to the application of NLP technologies., Materials and Methods: In our work, we evaluate the application of PLMs for automating the population of the Society of Thoracic Surgeons (STSs) adult cardiac surgery registry (ACS) procedural elements, for which we term Cardiovascular Surgery Bidirectional Encoder Representations from Transformers (CS-BERT). CS-BERT was validated across multiple satellite sites and versions of the STS-ACS registry., Results: CS-BERT performed well (F1 score of 0.8417 ± 0.1838) in common cardiac surgery procedures compared to models based on diagnosis codes (F1 score of 0.6130 ± 0.0010). The model also generalized well to satellite sites and across different versions of the STS-ACS registry., Discussion and Conclusions: This study provides evidence that PLMs can be used to extract the more common cardiac surgery procedure variables in the STS-ACS registry, potentially reducing need for expensive human annotation and wide scale dissemination. Further research is needed for rare procedural variables which suffer from both lack of data and variable documentation quality., Competing Interests: MG is a consultant to Edwards Lifesciences, Medtronic, Abbott, Artivion, ClearFlow, AtriCure, Johnson and Johnson, Corcym., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Background: This study investigated the safety and effectiveness of surgical aortic valve replacement with RESILIA tissue (Edwards Lifesciences) through 5 years in patients with native bicuspid aortic valves. Outcomes were compared with those for patients with tricuspid aortic valves., Methods: Of 689 patients from the COMMENCE (ProspeCtive, nOn-randoMized, MulticENter) trial who received the study valve, 645 had documented native valve morphology and core laboratory-evaluable echocardiograms from any postoperative visit, which were used to model hemodynamic outcomes over 5 years. Linear mixed-effects models were used to estimate longitudinal changes in mean gradient and effective orifice area., Results: Patients with native bicuspid aortic valves (n = 214) were more than a decade younger than those with tricuspid aortic valves (n = 458; 59.8 ± 12.4 years vs 70.2 ± 9.5 years; P < .001). The bicuspid aortic valve cohort exhibited no structural valve deterioration over 5 years, and rates of paravalvular leak and transvalvular regurgitation were low (0.7% and 2.9%, respectively [all mild] at 5 years). These outcomes mirrored those in patients with native tricuspid aortic valves. The model-estimated postoperative mean gradient and effective orifice area, as well as the rate of change of these outcomes, adjusted for age, body surface area, and bioprosthesis size, did not differ between the 2 cohorts., Conclusions: Among patients with bicuspid aortic valves, RESILIA tissue valves demonstrated excellent outcomes to 5 years, including no structural valve deterioration and very low rates of paravalvular and transvalvular regurgitation. These results are encouraging for RESILIA tissue durability in young patients., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

In this invited expert review, we focus on evolving lifetime management strategies for adolescents and young adults with congenital aortic valve disease, acknowledging that these patients often require multiple interventions during their lifetime. Our goal is to preserve the native aortic valve when feasible. Leveraging advanced multimodality imaging, a detailed assessment of the aortic valve and root complex can be obtained, and a surgically approach tailored to an individual patient's anatomy and pathology can be used. In turn, aortic valve repair and reconstruction can be offered to a greater number of patients, either as a definitive strategy or as a component of a staged strategy to delay the need for aortic valve replacement until later in life when more options are available., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Our objective was to compare the impact of patient-prosthesis mismatch (PPM) for 2 years after surgical aortic valve replacement within the prospective, randomized Placement of Aortic Transcatheter Valves (PARTNER) trials., Methods: Surgical aortic valve replacement patients from the PARTNER 1, 2, and 3 trials were included. PPM was classified as moderate (indexed effective orifice area ≤0.85 cm 2 /m 2 ) or severe (indexed effective orifice area ≤0.65 cm 2 /m 2 ). The primary endpoint was the composite of all-cause death and heart failure rehospitalization at 2 years., Results: By the predicted PPM method (PPM P ), 59.1% had no PPM, 38.8% moderate PPM, and 2.1% severe PPM; whereas by the measured PPM method (PPM M ), 42.4% had no PPM, 36.0% moderate, and 21.6% severe. Patients with no PPM P (23.6%) had a lower rate of the primary endpoint compared with patients with moderate (28.2%, P = .03) or severe PPM P (38.8%, P = .02). Using the PPM M method, there was no difference between the no (17.7%) and moderate PPM M groups (21.1%) in the primary outcome (P = .16). However, those with no PPM M or moderate PPM M were improved compared with severe PPM M (27.4%, P < .001 and P = .02, respectively)., Conclusions: Severe PPM analyzed by PPM P was only 2.1% for surgical aortic valve replacement patients. The PPM M method overestimated the incidence of severe PPM relative to PPM P , but was also associated with worse outcome. There was higher all-cause mortality in patients with severe PPM, thus surgical techniques to minimize PPM remain critical., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Patients with moderate aortic stenosis (AS) exhibit high morbidity and mortality. Limited evidence exists on the role of aortic valve replacement (AVR) in this patient population. To investigate the benefit of AVR in moderate AS on survival and left ventricular function., Methods: In a retrospective cohort study, patients with moderate AS between 2008 and 2016 were selected from the Cleveland Clinic echocardiography database and followed until 2018. Patients were classified as receiving AVR or managed medically (clinical surveillance). All-cause and cardiovascular mortality were assessed by survival analyses. Temporal haemodynamic and structural changes were assessed with longitudinal analyses using linear mixed effects models., Results: We included 1421 patients (mean age, 75.3±5.4 years and 39.9% women) followed over a median duration of 6 years. Patients in the AVR group had lower risk of all-cause (adjusted HR (aHR)=0.51, 95% CI: 0.34 to 0.77; p=0.001) and cardiovascular mortality (aHR=0.50, 95% CI: 0.31 to 0.80; p=0.004) compared with those in the clinical surveillance group irrespective of sex, receipt of other open-heart surgeries and underlying malignancy. These findings were seen only in those with preserved left ventricular ejection fraction (LVEF) ≥50%. Further, patients in the AVR group had a significant trend towards an increase in LVEF and a decrease in right ventricular systolic pressure compared with those in the clinical surveillance group., Conclusions: In patients with moderate AS, AVR was associated with favourable clinical outcomes and left ventricular remodelling., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Significant controversy continues to confound patient selection and referral for revascularization and mitral valve intervention in patients with ischemic cardiomyopathy (ICM). Cardiac magnetic resonance (CMR) enables comprehensive phenotyping with gold-standard tissue characterization and volumetric/functional measures. Therefore, we sought to determine the impact of CMR-enriched phenomapping patients with ICM to identify differential outcomes following surgical revascularization and surgical mitral valve intervention (sMVi)., Methods: Consecutive patients with ICM referred for CMR between 2002 and 2017 were evaluated. Latent class analysis was performed to identify phenotypes enriched by comprehensive CMR assessment. The primary end point was death, heart transplant, or left ventricular assist device implantation. A multivariable Cox survival model was developed to determine the association of phenogroups with overall survival. Subgroup analysis was performed to assess the presence of differential response to post-magnetic resonance imaging procedural interventions., Results: A total of 787 patients were evaluated (63.0±11.2 years, 24.8% women), with 464 primary events. Subsequent surgical revascularization and sMVi occurred in 380 (48.3%) and 157 (19.9%) patients, respectively. Latent class analysis identified 3 distinct clusters of patients, which demonstrated significant differences in overall outcome ( P <0.001). Latent class analysis identified differential survival benefit of revascularization in patients as well as patients who underwent revascularization with sMVi, based on phenogroup classification, with phenogroup 3 deriving the most survival benefit from revascularization and revascularization with sMVi (hazard ratio, 0.61 [0.43-0.88]; P =0.0081)., Conclusions: CMR-enriched unsupervised phenomapping identified distinct phenogroups, which were associated with significant differential survival benefit following surgical revascularization and sMVi in patients with ICM. Phenomapping provides a novel approach for patient selection, which may enable personalized therapeutic decision-making for patients with ICM., Competing Interests: Disclosures Dr W.H. Wilson Tang is a consultant for Sequana Medical, Cardiol Therapeutics, Genomics plc, Zehna Therapeutics, Boston Scientific, WhiteSwell, Inc, Kiniksa Pharmaceuticals, CardiaTec Biosciences, Intellia Therapeutics, and has received honoraria from Springer Nature, Belvoir Media Group, and American Board of Internal Medicine. Dr Deborah Kwon is funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health under 1R01HL170090-01. Dr Kwon also had a research agreement with Circle cvi42. Dr Xiaofeng Wang is funded by the National Institute of General Medical Sciences of the National Institutes of Health under 1R01GM152717.

Background: Postacute sequelae of COVID-19 (PASC), also referred to as "Long COVID", sometimes follows COVID-19, a disease caused by SARS-CoV-2. Although SARS-CoV-2 is well known to promote a prothrombotic state, less is known about the thrombosis risk in PASC. Our objective was to evaluate platelet function and thrombotic potential in patients following recovery from SARS-CoV-2, but with clear symptoms of patients with PASC., Methods: patients with PASC and matched healthy controls were enrolled in the study on average 15 months after documented SARS-CoV-2 infection. Platelet activation was evaluated by light transmission aggregometry (LTA) and flow cytometry in response to platelet surface receptor agonists. Thrombosis in platelet-deplete plasma was evaluated by Factor Xa activity. A microfluidics system assessed thrombosis in whole blood under shear stress conditions., Results: A mild increase in platelet aggregation in patients with PASC through the thromboxane receptor was observed, and platelet activation through the glycoprotein VI (GPVI) receptor was decreased in patients with PASC compared to age- and sex-matched healthy controls. Thrombosis under shear conditions as well as Factor Xa activity were reduced in patients with PASC. Plasma from patients with PASC was an extremely potent activator of washed, healthy platelets - a phenomenon not observed when stimulating healthy platelets after incubation with plasma from healthy individuals., Conclusions: patients with PASC show dysregulated responses in platelets and coagulation in plasma, likely caused by a circulating molecule that promotes thrombosis. A hitherto undescribed protective response appears to exist in patients with PASC to counterbalance ongoing thrombosis that is common to SARS-CoV-2 infection., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To determine mechanisms of early and late failure after mitral valve repair for degenerative disease, identify factors associated with re-repair, and evaluate durability of re-repair., Methods: From January 2008 to July 2020, 330 reoperations were performed for recurrent mitral valve dysfunction after initial valve repair for degenerative disease. Mechanisms of repair failure were determined by review of preoperative imaging and operative reports. Multivariable analysis was performed to identify factors associated with likelihood of re-repair or replacement. Durability of re-repair was assessed using longitudinal analysis of postoperative echo data., Results: Eighty-five of 330 (26%) reoperations were performed for early repair failure within 1 year and 245/330 (74%) for late failure thereafter. Suture/annuloplasty dehiscence, systolic anterior motion, hemolysis, and ventricular remodeling were more common mechanisms of early failure and disease progression and fibrosis late failure. Forty percent (34/85) of early failures were re-repaired versus 24% (59/245) of late failures. Re-repair was more common than replacement in recent years and was associated with earlier reoperation (median 1.5 vs 3.9 years; P = .0001). No in-hospital deaths occurred after re-repair; 2 patients (0.8%) died after valve replacement. Freedom from severe mitral regurgitation after re-repair was 93% at 7 years., Conclusions: Mitral valve re-repair can be performed with low rates of mortality and morbidity for early and late valve dysfunction. Mechanisms of early repair failure differ from those of late failure and are generally more amenable to re-repair. In selected patients who present after failed repair, we prefer mitral re-repair to valve replacement whenever technically feasible., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Background: Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death., Objectives: The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors., Methods: From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE)., Results: Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse., Conclusions: Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue., Competing Interests: Funding Support and Author Disclosures Support was provided by the Drs Sidney and Becca Fleischer Heart and Vascular Education Chair (to Dr Blackstone), The Peter and Elizabeth C. Tower Family Endowed Chair in Cardiothoracic Research (to Dr Unai), James and Sharon Kennedy, The Slosburg Family Charitable Trust, and The Stephen and Saundra Spencer Fund for Cardiothoracic Research. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

This consensus of nomenclature and classification for congenital bicuspid aortic valve and its aortopathy is evidence-based and intended for universal use by physicians (both pediatricians and adults), echocardiographers, advanced cardiovascular imaging specialists, interventional cardiologists, cardiovascular surgeons, pathologists, geneticists, and researchers spanning these areas of clinical and basic research. In addition, as long as new key and reference research is available, this international consensus may be subject to change based on evidence-based data1.

Objective: An increasing number of patients with significant comorbidities present for complex cardiac surgery, with a subgroup requiring discharge to long-term acute care facilities. We aim to examine predictors and mortality after discharge to a long-term acute care facility., Methods: From January 1, 2015, to April 30, 2021, all adult cardiac surgeries were queried and patients discharged to long-term acute care facilities were identified. Baseline characteristics, procedures, and in-hospital complications were compared between long-term acute care facility and non-long-term acute care facility discharges. Random forest analysis was conducted to establish predictors of discharge to long-term acute care facilities. Kaplan-Meier survival analysis was used to determine probability of survival over 7 years. Multivariate regression modeling was used to establish predictors of death after long-term acute care facility discharge., Results: Of 29,884 patients undergoing cardiac surgery, 324 (1.1%) were discharged to a long-term acute care facility. The long-term acute care facility group had higher rates of urgent/emergency operation (54% vs 23%; 10% vs 3%, P < .001) and longer mean cardiopulmonary bypass (167 vs 110 minutes, P < .001). By random forest analysis, emergency/urgent status, longer cardiopulmonary bypass duration, redo surgery, endocarditis, and history of dialysis were the most predictive of discharge to a long-term acute care facility. Although the non-long-term acute care facility group demonstrated greater than 95% survival at 6 months, Kaplan-Meier survival analysis showed 28% 6-month mortality in the long-term acute care facility cohort. Random forest analysis demonstrated that chronic lung disease and postoperative respiratory complications were significant predictors of death at 6 months after discharge to a long-term acute care facility., Conclusions: Patients with chronic lung and kidney disease undergoing prolonged procedures are at higher risk to be discharged to long-term acute care facilities after surgery with worse survival. Efforts to minimize postoperative respiratory complications may reduce mortality after discharge to long-term acute care facilities., Competing Interests: Conflict of Interest Statement A.M.G. is a consultant for AtriCure, Medtronic, Edwards Lifesciences, Abbott, CryoLife, and ClearFlow. H.E. has a financial relationship with Edwards Lifesciences and LifeNet Health. 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 © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To maximize successful repair of bicuspid aortic valves by adding figure-of-8 hitch-up stitches at commissures., Methods: From 2000 to 2022, bicuspid aortic valve repair was performed on 1112 patients at Cleveland Clinic, with 367 patients receiving figure-of-8 hitch-up stitches along with classical techniques, including Cabrol suture, cusp plication, raphe resection, and valve-sparing root replacement. Operative outcomes, repair durability, and survival were assessed in the figure-of-8 hitch-up stitches cohort, and outcomes were compared among 195 balancing-score-matched patient pairs who underwent bicuspid aortic valve repair with and without figure-of-8 hitch-up stitches., Results: Patients who underwent bicuspid aortic valve repair with figure-of-8 stitches had an operative mortality of 0.3% (1 of 367) and in-hospital reoperation for aortic valve dysfunction of 1.1% (4 of 367). At 10 years, prevalence of severe aortic regurgitation was 8.6%, mean gradient 24 mm Hg, freedom from aortic valve reoperation 75%, and survival 98%. In matched cohorts, operative mortality was similar (0.51% vs 0%; P  > .9) as were morbidities, including in-hospital reoperation due to aortic valve dysfunction (1.0% vs 1.5%; P  > .9). Comparable long-term outcomes were observed at 10 years (prevalence of severe aortic regurgitation of 8.7% vs 5.0% [ P  = .11], mean gradient 18 vs 17 mm Hg [ P  = .40]; freedom from aortic valve reoperation 80% vs 81% [ P  = .73]; and survival 99.5% vs 94.6% [ P  = .18])., Conclusions: Figure-of-8 hitch-up stitch is a safe bicuspid aortic valve repair technique. It increases the likelihood of a successful repair without increasing risk of cusp tear and achieves satisfactory long-term survival and durability when added to classical repair techniques., Competing Interests: Dr Desai has consultant and research agreements with Bristol Myers Squibb, Tenaya, and Cytokinetic, and is a consultant for Medtronic. Dr Vargo is a speaker for Edwards Lifesciences and a consultant for Artivion and Cellphire. Dr Roselli is a consultant, investigator, and speaker for Artivion, Edwards Lifesciences, WL Gore, Medtronic, and Terumo Aortic; a speaker for Cook Medical, Corcym, and JenaValve; and has a license with Artivion. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2024 The Author(s).)

Background: Prior studies have demonstrated worse long-term outcomes for women after surgery for severe mitral regurgitation (MR). The current Class I indications for surgery for severe degenerative MR use cutoffs of left ventricular end-systolic dimension (LVESD) and left ventricular ejection fraction (EF) that do not account for known sex-related differences., Objectives: The primary objective of this study was to assess long-term mortality following mitral valve repair in women compared with men on the basis of preoperative left ventricular systolic dimensions and EF., Methods: Consecutive patients who underwent isolated mitral valve repair for degenerative MR at a single institution between 1994 and 2016 were screened. Adjusted HRs for all-cause mortality were compared according to baseline LVESD, LVESD indexed to body surface area (LVESDi), and EF for men and women., Results: Among 4,589 patients, 1,825 were women (40%), and after a median follow-up period of 7.2 years, 344 patients (7.5%) had died. The risk for mortality for women increased from the baseline hazard at an LVESD of 3.6 cm, whereas an inflection point for increased risk with LVESD was not evident in men. Regarding LVESDi, the risk for women increased at 1.8 cm/m 2 compared with 2.1 cm/m 2 in men. For EF, women and men had a similar inflection point (58%); however, mortality was higher for women as EF decreased., Conclusions: After mitral valve repair, women have a higher risk for all-cause mortality at lower LVESD and LVESDi and higher EF. These results support consideration of sex-specific thresholds for LVESDi in surgical decision making for patients with severe MR., Competing Interests: Funding Support and Author Disclosures This work was supported by Women’s Cardiovascular Research at the Cleveland Clinic. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To characterize residual aortic regurgitation (AR), identify its risk factors, and evaluate outcomes following aortic root replacement with aortic valve reimplantation., Methods: From 2002 to 2020, 756 patients with a tricuspid aortic valve underwent elective reimplantation for aortic root aneurysm. AR on transthoracic echocardiograms before hospital discharge was graded as mild or greater. Machine learning was used to identify risk factors for residual AR and subsequent aortic valve reoperation., Results: Sixty-five patients (8.6%) had mild (58 [7.7%]) or moderate (7 [0.93%]) residual postoperative AR. They had more severe preoperative AR (38% vs 12%; P < .0001), thickened cusps (7.7% vs 2.2%; P = .008), aortic valve repair (38% vs 23%; P = .004), and multiple returns to cardiopulmonary bypass for additional repair (11% vs 3.3%; P = .003) than those without AR. Predictors of residual AR were severe preoperative AR, smaller aortic root graft, and concomitant cusp repair. At 10 years, patients with versus without residual AR had more moderate or severe AR (48% vs 7.0%; P < .0001) and freedom from reoperation was worse (89% vs 98%; P < .0001). Residual AR was a risk factor for early reoperation. Concomitant coronary bypass, lower body mass index, and lower ejection fraction were risk factors for late reoperation. Ten-year survival was similar among patients with and without residual AR (97% vs 93%; P = .43)., Conclusions: Residual AR after elective reimplantation of a tricuspid aortic valve for aortic root aneurysm is uncommon. Patients with severe preoperative AR and those who undergo valve repair have higher risk for residual AR, which can progress and increase risk of aortic valve reoperation., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Patient characteristics, risks, and outcomes associated with reoperative multivalve cardiac surgery are poorly characterized. Effect of patient variables and surgical components of each reoperation were evaluated with regard to operative mortality., Methods: From January 2008 to January 2022, 2324 patients with previous cardiac surgery underwent 2352 reoperations involving repair or replacement of multiple cardiac valves at Cleveland Clinic. Mean age was 66 ± 14 years. Number of surgical components representing surgical complexity (valve procedures, aortic surgery, coronary artery bypass grafting, and atrial fibrillation procedures) ranged from 2 to 6. Random forest for imbalanced data was used to identify risk factors for operative mortality., Results: Surgery was elective in 1327 (56%), urgent in 1006 (43%), and emergency in 19 (0.8%). First-time reoperations were performed in 1796 (76%) and 556 (24%) had 2 or more previous operations. Isolated multivalve operations comprised 54% (1265) of cases; 1087 incorporated additional surgical components. Two valves were operated on in 80% (1889) of cases, 3 in 20% (461), and 4 in 0.09% (2). Operative mortality was 4.2% (98 out of 2352), with 1.7% (12 out of 704) for elective, isolated multivalve reoperations. For each added surgical component, operative mortality incrementally increased, from 2.4% for 2 components (24 out of 1009) to 17% for ≥5 (5 out of 30). Predictors of operative mortality included coronary artery bypass grafting, surgical urgency, cardiac, renal dysfunction, peripheral artery disease, New York Heart Association functional class, and anemia., Conclusions: Elective, isolated reoperative multivalve surgery can be performed with low mortality. Surgical complexity coupled with key physiologic factors can be used to inform surgical risk and decision making., 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 manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Objective: The study objective was to determine the effect of sinutubular junction stabilization on long-term outcomes of bicuspid aortic valve repair., Methods: From January 1998 to January 2020, 419 patients underwent bicuspid aortic valve repair with ascending aorta replacement and 421 without (bicuspid aortic valve repair alone). Propensity score matching (97 pairs) was used to compare outcomes., Results: Before matching, prevalence of severe aortic regurgitation at 10 years was 5.4% after bicuspid aortic valve repair + ascending aorta replacement and 10% after bicuspid aortic valve repair alone; aortic valve gradient was 20 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 19 mm Hg after bicuspid aortic valve repair alone. Ten-year freedom from reoperation overall was 79% after bicuspid aortic valve repair + ascending aorta replacement and 75% after bicuspid aortic valve repair alone; freedom from late aortic regurgitation was 93% after bicuspid aortic valve repair + ascending aorta replacement and 92% after bicuspid aortic valve repair alone; and freedom from aortic stenosis was 87% after bicuspid aortic valve repair + ascending aorta replacement and 93% after bicuspid aortic valve repair alone. Ten-year survival was 95% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone. After matching, prevalence of severe aortic regurgitation at 10 years was 11% after bicuspid aortic valve repair + ascending aorta replacement and 9.1% after bicuspid aortic valve repair alone (P = .33); aortic valve gradient was 16 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 25 mm Hg after bicuspid aortic valve repair alone (P < .0001). Ten-year freedom from reoperation was 85% after bicuspid aortic valve repair + ascending aorta replacement and 72% after bicuspid aortic valve repair alone (P = .08) overall. Ten-year freedom from reoperation for late aortic regurgitation was 88% after bicuspid aortic valve repair + ascending aorta replacement and 86% after bicuspid aortic valve repair alone (P = .65). Freedom from aortic stenosis was 97% after bicuspid aortic valve repair + ascending aorta replacement and 91% after bicuspid aortic valve repair alone (P = .03). Ten-year survival was 96% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone (P = .16)., Conclusions: Bicuspid aortic valve repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Bicuspid aortic valve repair + ascending aorta replacement has a minimal effect on long-term repair durability. Sinutubular junction stabilization should not be performed for the sole purpose of long-term repair durability., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The durability of reimplanted myxomatous aortic valves in root replacements for patients with connective tissue disorders (CTD) is unclear; therefore, we sought to evaluate the long-term resilience of these repairs., Methods: From January 1980 to January 2020, 214 patients with CTD and 645 without CTD underwent primary, elective aortic valve reimplantation operations at Cleveland Clinic. The CTD cohort included 164 (77%) with Marfan, 23 (11%) with Loeys-Dietz, and 7 (3.3%) with Ehlers-Danlos CTD. We accounted for differing patient characteristics between the groups by propensity score matching to compare outcomes, yielding 96 matched pairs. Longitudinal echocardiographic measures were compared using nonlinear mixed effects models., Results: In the CTD cohort, there were no operative mortalities (30-day or in-hospital), 1 (0.47%) stroke, and 1 (0.47%) early in-hospital reoperation for valve dysfunction. Ten-year prevalence of no aortic regurgitation was 86%, mild 11%, and moderate 3%. Ten-year freedom from reoperation was 97%. In propensity matched cohorts, there were no significant differences in in-hospital outcomes, longitudinal aortic regurgitation and mean gradient, risk of reoperation on the aortic valve, or risk of late death., Conclusions: Aortic valve reimplantation is a durable operation in patients with CTD and root aneurysms. These patients do not experience early degeneration of their reimplanted aortic valves., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Importance: Preclinical studies suggest a potential role for aspirin in slowing abdominal aortic aneurysm (AAA) progression and preventing rupture. Evidence on the clinical benefit of aspirin in AAA from human studies is lacking., Objective: To investigate the association of aspirin use with aneurysm progression and long-term clinical outcomes in patients with AAA., Design, Setting, and Participants: This was a retrospective, single-center cohort study. Adult patients with at least 2 available vascular ultrasounds at the Cleveland Clinic were included, and patients with history of aneurysm repair, dissection, or rupture were excluded. All patients were followed up for 10 years. Data were analyzed from May 2022 to July 2023., Main Outcomes and Measures: Clinical outcomes were time-to-first occurrence of all-cause mortality, major bleeding, or composite of dissection, rupture, and repair. Multivariable-adjusted Cox proportional-hazard regression was used to estimate hazard ratios (HR) for all-cause mortality, and subhazard ratios competing-risk regression using Fine and Gray proportional subhazards regression was used for major bleeding and composite outcome. Aneurysm progression was assessed by comparing the mean annualized change of aneurysm diameter using multivariable-adjusted linear regression and comparing the odds of having rapid progression (annual diameter change >0.5 cm per year) using logistic regression., Results: A total of 3435 patients (mean [SD] age 73.7 [9.0] years; 2672 male patients [77.5%]; 120 Asian, Hispanic, American Indian, or Pacific Islander patients [3.4%]; 255 Black patients [7.4%]; 3060 White patients [89.0%]; and median [IQR] follow-up, 4.9 [2.5-7.5] years) were included in the final analyses, of which 2150 (63%) were verified to be taking aspirin by prescription. Patients taking aspirin had a slower mean (SD) annualized change in aneurysm diameter (2.8 [3.0] vs 3.8 [4.2] mm per year; P = .001) and lower odds of having rapid aneurysm progression compared with patients not taking aspirin (adjusted odds ratio, 0.64; 95% CI, 0.49-0.89; P = .002). Aspirin use was not associated with risk of all-cause mortality (adjusted HR [aHR], 0.92; 95% CI, 0.79-1.07; P = .32), nor was aspirin use associated with major bleeding (aHR, 0.88; 95% CI, 0.76-1.03; P = .12), or composite outcome (aHR, 1.16; 95% CI, 0.93-1.45; P = .09) at 10 years., Conclusions: In this retrospective study of a clinical cohort of 3435 patients with objectively measured changes in aortic aneurysm growth, aspirin use was significantly associated with slower progression of AAA with a favorable safety profile.

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements., Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs)., Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P  = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P  = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P  = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% ( P  = .33) and 87% versus 100% ( P  = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P  = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively ( P  = .47)., Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach., Competing Interests: 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., (© 2023 The Author(s).)

Background: The Ozaki procedure using autologous pericardium is an interesting but complex alternative for aortic valve replacement. We present a standardized approach to minimize the learning curve and confirm reproducibility., Methods: After careful preparation, from May 2015 to February 2021, an Ozaki procedure was performed on 46 patients age 51 ± 14 years. Seven had unicuspid (15%), 29 bicuspid (63%), and 10 tricuspid (22%) aortic valves, and 2 patients had endocarditis. Endpoints were operative learning curves, perioperative outcomes, intermediate-term valve hemodynamics, reintervention, health-related quality of life (MacNew Heart Disease Health-Related Quality of Life questionnaire), and mortality., Results: Cardiopulmonary bypass and aortic clamp times decreased from 145 to 125 ​minutes and 120 to 100 ​minutes, respectively, over the first 20 cases, reflecting the learning curve. There was no major perioperative morbidity or mortality. Median postoperative stay was 6.9 days. Aortic regurgitation was mild or less in all but 2 patients who developed moderate aortic regurgitation. Mean aortic valve gradient was 7.9 mmHg postoperatively, 9.2 mmHg by 6 months, and constant thereafter. Left ventricular ejection fraction was 58% preoperatively, 60% at 6 months, and remained stable thereafter. One patient developed infective endocarditis 7 months postoperatively, failed medical management, and underwent valve replacement at 14 months. Two-year survival was 96%, with 1 noncardiac death at 16 months. Health-related quality of life in mental, physical, and emotional domains was better than matched norms, global 6.2 vs. 5.0 ( p < 0.0001)., Conclusions: Using a well-prepared standardized approach, the Ozaki procedure is reproducible with a short learning curve, excellent hemodynamic performance, and good quality of life., Competing Interests: Dr Blackstone had statistical consultation related to valve trials with Edwards Lifesciences and Abiomed. The other authors had no conflicts to declare., (© 2023 The Author(s).)