Search

Abdominal Aortic Aneurysms (AAA) remain a clinically devastating disease with no effective medical treatment therapy. AAAs are characterized by immune cell infiltration, smooth muscle cell apoptosis, and extracellular matrix degradation. Interleukin-1 (IL-1) has been shown to play role in AAA associated inflammation through immune cell recruitment and activation, endothelial dysfunction, production of reactive oxygen species (ROS), and regulation of transcription factors of additional inflammatory mediators. In this review, we will discuss the principles of IL-1 signaling, its role in AAA specific inflammation, and regulators of IL-1 signaling. Additionally, we will discuss the influence of genetic and pharmacological inhibitors of IL-1 on experimental AAAs. Evidence suggests that IL-1 may prove to be a potential therapeutic target in the management of AAA disease.

Background: Aging enhances most chronic diseases but its impact on human aortic tissue in health and in thoracic aortic aneurysms (TAA) remains unclear. Methods: We employed a human aortic biorepository of healthy specimens (n=17) and those that underwent surgical repair for TAA (n=20). First, we performed proteomics comparing aortas of healthy donors to aneurysmal specimens, in young (ie, Results: Proteomics revealed that aging transformed the aorta both quantitatively and qualitatively from health to TAA. Whereas young aortas exhibited an enrichment of immunologic processes, older aortas exhibited an enrichment of metabolic processes. Immunoblotting revealed that the expression of Parkin directly correlated to subject age in health but inversely to subject age in TAA. In TAA, but not in health, phosphorylation of STING and the expression of IFN-β was impacted by aging regardless of whether subjects had bicuspid or tricuspid valves. In subjects with bicuspid valves and TAAs, TLR9 expression positively correlated with subject age. Interestingly, whereas phosphorylation of STING was inversely correlated with subject age, IFN-β positively correlated with subject age. Conclusions: Aging transforms the human aortic proteome from health to TAA, leading to a differential regulation of biological processes. Our results suggest that the development of therapies to mitigate vascular diseases including TAA may need to be modified depending on subject age.

Interleukin-1 (IL-1) signaling has an established role as a cytokine signaling pathway important for progression of abdominal aortic aneurysms (AAAs). While the IL-1β ligand and IL-1R1 have been previously investigated, the role of the IL-1α ligand in AAAs remains unknown. In this study, we sought to examine the role of IL-1α in AAAs using genetic and pharmacologic approaches.Eight-week-old wild-type (WT) or IL-1α knock-out (KO) male and female mice (n = 10-16/group) underwent experimental AAA and were harvested 14 days following surgery to assess AAA size and characteristics. In separate studies, 8-week-old WT mice were treated with an inhibitor to IL-1α during AAA formation and harvested 14 days following surgery. Finally, WT and IL-1α KO mice were administered Anakinra, an IL-R1 inhibitor, during AAA formation to determine the effect of inhibiting IL-1R1 when IL-1α is knocked out.Male and female IL-1α KO mice had larger AAAs compared to WT AAAs (male: 153% vs. 89.2%, P = 0.0001; female: 86.6% vs. 63.5%, P = 0.02). IL-1α KO mice had greater elastin breakage (P = 0.01), increased levels of macrophage staining (P = 0.0045), and greater pro-metallo proteinase 2 (P = 0.02). Pharmacologic inhibition of WT male mice with an IL-1α neutralizing antibody resulted in larger AAAs (133.1% vs. 77.0%, P 0.001). Finally, treatment of IL-1α KO male mice with Anakinra decreased AAA formation compared with vehicle control AAAs (Anakinra + IL-1α KO: 47.7% vs. WT: 147.1%; P = 0.0001).IL-1α disruption using either genetic or pharmacologic approaches worsens AAAs.

Refractory right ventricular failure at the time of left ventricular assist device implantation requires treatment with supplemental mechanical circulatory support. However, the optimal strategy for support remains unknown.All patients undergoing first-time durable left ventricular assist device implantation with a contemporary device were selected from The Society of Thoracic Surgeons National Database (2011 to 2019). Patients requiring right ventricular assist device (RVAD) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) were included in the analysis. Patients were stratified by RVAD or VA-ECMO and by timing of placement (intraoperative vs postoperative).In all, 18 423 left ventricular assist device implants were identified, of which 940 (5.1%) required RVAD (n = 750) or VA-ECMO (n = 190) support. Patients receiving an RVAD more frequently had preoperative inotrope requirement (76% vs 62%, P.01) and severe tricuspid regurgitation (20% vs 13%, P.01). The RVAD patients had lower rates of postoperative renal failure (40% vs 51%, P = .02) and limb ischemia (4% vs 13%, P.01), as well as significantly less operative mortality (41% vs 54%, P.01). After risk adjustment with propensity score analysis, support with VA-ECMO was associated with a higher risk of mortality (risk ratio 1.46; 95% confidence interval, 1.21 to 1.77; P.01) compared with patients receiving an RVAD. Importantly, institution of right ventricular support postoperatively was associated with higher mortality (1.43, P.01) compared with intraoperative initiation.Patients with severe right ventricular failure in the setting of durable left ventricular assist device implantation may benefit from the use of RVAD over VA-ECMO. Regardless of the type of support, initiation at the index operation was associated with improved outcomes.

BACKGROUND: Coronary artery bypass grafting (CABG) is the most common revascularization approach for the treatment of multi-vessel coronary artery disease. While the internal mammary artery is nearly universally used to bypass the left anterior descending coronary artery, autologous saphenous vein grafts (SVGs) are still the most frequently used conduits to grafts the remaining coronary artery targets Long-term failure of these grafts, however, continues to limit the benefits of surgery. DESIGN: The Cardiothoracic Surgical Trials Network trial of the safety and effectiveness of a Venous External Support (VEST) device is a randomized, multicenter, within-patient trial comparing VEST-supported versus unsupported saphenous vein grafts in patients undergoing CABG. Key inclusion criteria are the need for CABG with a planned internal mammary artery to the left anterior descending and two or more saphenous vein grafts to other coronary arteries. The primary efficacy endpoint of the trial is SVG intimal hyperplasia (plaque + media) area assessed by intravascular ultrasound at 12 months post randomization. Occluded grafts are accounted for in the analysis of the primary endpoint. Secondary confirmatory endpoints are lumen diameter uniformity and graft failure (>50% stenosis) assessed by coronary angiography at 12 months. The safety endpoints are the occurrence of major adverse cardiac and cerebrovascular events and hospitalization within 5 years from randomization. CONCLUSIONS: The results of the VEST trial will determine whether the VEST device can safely limit SVG intimal hyperplasia in patients undergoing CABG as treatment for coronary atherosclerotic disease.

BACKGROUND The association, if any, between the effective regurgitant orifice (EROA) to left ventricular end-diastolic volume (LVEDV) ratio and 1-year mortality is controversial in patients undergoing mitral transcatheter edge-to-edge repair (m-TEER) with the MitraClip™ system. The objective is to determine the association between EROA/LVEDV and 1-year mortality among patients undergoing m-TEER with MitraClip™. METHODS In patients with severe secondary (functional) mitral regurgitation (MR), we analyzed registry data from 11 centers using generalized linear models with the generalized estimating equations approach. RESULTS We studied 525 patients with secondary MR who underwent m-TEER in 11 centers. Most patients were male (63%) and were NYHA class III (61%) or IV (21%). MR was caused by ischemic cardiomyopathy in 51% of patients. EROA/LVEDV values varied widely with median=0.19 mm2/mL, interquartile range [0.12,0.28] mm2/mL, and 187 (36%) patients had values

Background The current standard of care for the treatment of patients with primary mitral regurgitation (MR) is surgical mitral valve repair. Transcatheter edge‐to‐edge repair with the MitraClip device provides a less invasive treatment option for patients with both primary and secondary MR. Worldwide, >150 000 patients have been treated with the MitraClip device. However, in the United States, MitraClip is approved for use only in primary patients with MR who are at high or prohibitive risk for mitral valve surgery. The REPAIR MR (Percutaneous MitraClip Device or Surgical Mitral Valve Repair in Patients With Primary Mitral Regurgitation Who Are Candidates for Surgery) trial is designed to compare early and late outcomes associated with transcatheter edge‐to‐edge repair with the MitraClip and surgical repair of primary MR in older or moderate surgical risk patients. Methods and Results The REPAIR MR trial is a prospective, randomized, parallel‐controlled, open‐label multicenter, noninferiority trial for the treatment of severe primary MR (verified by an independent echocardiographic core laboratory). Patients with severe MR and indications for surgery because of symptoms (New York Heart Association class II–IV), or without symptoms with left ventricular ejection fraction ≤60%, pulmonary artery systolic pressure >50 mm Hg, or left ventricular end‐systolic diameter ≥40 mm are eligible for the trial provided they meet the moderate surgical risk criteria as follows: (1) ≥75 years of age, or (2) if Conclusions The REPAIR MR trial will determine the safety and effectiveness of transcatheter edge‐to‐edge repair with the MitraClip in patients with primary MR who are at moderate surgical risk and are candidates for surgical MV repair. The trial will generate contemporary comparative clinical evidence for the MitraClip device and surgical MV repair. Registration https://clinicaltrials.gov/ct2/show/NCT04198870 ; NCT04198870.

Tricuspid regurgitation is common in patients with severe degenerative mitral regurgitation. However, the evidence base is insufficient to inform a decision about whether to perform tricuspid-valve repair during mitral-valve surgery in patients who have moderate tricuspid regurgitation or less-than-moderate regurgitation with annular dilatation.We randomly assigned 401 patients who were undergoing mitral-valve surgery for degenerative mitral regurgitation to receive a procedure with or without tricuspid annuloplasty (TA). The primary 2-year end point was a composite of reoperation for tricuspid regurgitation, progression of tricuspid regurgitation by two grades from baseline or the presence of severe tricuspid regurgitation, or death.Patients who underwent mitral-valve surgery plus TA had fewer primary-end-point events than those who underwent mitral-valve surgery alone (3.9% vs. 10.2%) (relative risk, 0.37; 95% confidence interval [CI], 0.16 to 0.86; P = 0.02). Two-year mortality was 3.2% in the surgery-plus-TA group and 4.5% in the surgery-alone group (relative risk, 0.69; 95% CI, 0.25 to 1.88). The 2-year prevalence of progression of tricuspid regurgitation was lower in the surgery-plus-TA group than in the surgery-alone group (0.6% vs. 6.1%; relative risk, 0.09; 95% CI, 0.01 to 0.69). The frequencies of major adverse cardiac and cerebrovascular events, functional status, and quality of life were similar in the two groups at 2 years, although the incidence of permanent pacemaker implantation was higher in the surgery-plus-TA group than in the surgery-alone group (14.1% vs. 2.5%; rate ratio, 5.75; 95% CI, 2.27 to 14.60).Among patients undergoing mitral-valve surgery, those who also received TA had a lower incidence of a primary-end-point event than those who underwent mitral-valve surgery alone at 2 years, a reduction that was driven by less frequent progression to severe tricuspid regurgitation. Tricuspid repair resulted in more frequent permanent pacemaker implantation. Whether reduced progression of tricuspid regurgitation results in long-term clinical benefit can be determined only with longer follow-up. (Funded by the National Heart, Lung, and Blood Institute and the German Center for Cardiovascular Research; ClinicalTrials.gov number, NCT02675244.).

Despite the rapid adoption of transcatheter aortic replacement (TAVR), surgical TAVR valve explantation (TAVR-explant) and the clinical impact of explanted TAVR device type are not well described.TAVR-explant from 2016 to 2019 was queried using the Society of Thoracic Surgeons (STS) National Database. A total of 483 patients with documented explanted valve type, consisting of 330 (68%) patients with balloon-expandable and 153 (32%) patients with self-expandable devices, were identified. The primary outcome was 30-day mortality. The secondary outcome was the need for any simultaneous procedures with TAVR-explant.The mean age was 72.8 years, 38% of the patients were female, and 51% demonstrated New York Heart Association functional class III to IV symptoms. During TAVR-explant, 63% of patients required other simultaneous procedures, including aortic repair (27%), mitral procedures (22%), coronary artery bypass grafting (15%), and tricuspid procedures (7%). Patients with a self-expandable device underwent more frequent ascending aortic replacement (22% vs 9%; P.001) than those with a balloon-expandable device, whereas the aortic root replacement rate was similar (19% vs 24%; P = .22). The overall 30-day mortality was 18% without differences in the mortality or other major complications between the groups. Of the 157 patients with isolated surgical aortic valve replacement and available STS predicted risk of mortality score, the observed-to-expected (O/E) mortality ratio was 2.2.The TAVR-explant outcomes were comparable between patients with balloon-expandable devices and patients with self-expandable devices, whereas ascending aortic replacement was observed more frequently in patients with self-expandable devices. Younger patients undergoing TAVR should be informed of the future TAVR-explant risk that may accompany a higher O/E ratio and frequent morbid concurrent procedures.

Background Thoracic aortic aneurysms (TAA) are a progressive disease characterized by inflammation, smooth muscle cell activation and matrix degradation. We hypothesized that mesenchymal stem cells (MSCs) can immunomodulate vascular inflammation and remodeling via altered microRNA (miRNAs) expression profile to attenuate TAA formation. Materials and methods C57BL/6 mice underwent topical elastase application to form descending TAAs. Mice were also treated with MSCs on days 1 and 5 and aortas were analyzed on day 14 for aortic diameter. Cytokine array was performed in aortic tissue and total RNA was tagged and hybridized for miRNAs microarray analysis. Immunohistochemistry was performed for elastin degradation and leukocyte infiltration. Results Treatment with MSCs significantly attenuated aortic diameter and TAA formation compared to untreated mice. MSC administration also attenuated T-cell, neutrophil and macrophage infiltration and prevented elastic degradation to mitigate vascular remodeling. MSC treatment also attenuated aortic inflammation by decreasing proinflammatory cytokines (CXCL13, IL-27, CXCL12 and RANTES) and upregulating anti-inflammatory interleukin-10 expression in aortic tissue of elastase-treated mice. TAA formation demonstrated activation of specific miRNAs that are associated with aortic inflammation and vascular remodeling. Our results also demonstrated that MSCs modulate a different set of miRNAs that are associated with decrease leukocyte infiltration and vascular inflammation to attenuate the aortic diameter and TAA formation. Conclusions These results indicate that MSCs immunomodulate specific miRNAs that are associated with modulating hallmarks of aortic inflammation and vascular remodeling of aortic aneurysms. Targeted therapies designed using MSCs and miRNAs have the potential to regulate the growth and development of TAAs.

B cell–activating factor (BAFF), part of a tumor necrosis factor family of cytokines, was recently identified as a regulator of atherosclerosis; however, its role in aortic aneurysm has not been determined. Here, the study examined the effect of selective BAFF antagonism using an anti-BAFF antibody (blocks binding of BAFF to receptors BAFF receptor 3, transmembrane activator and CAML interactor, and B-cell maturation antigen) and mBaffR-mFc (blocks binding of BAFF to BAFF receptor 3) on a murine model of abdominal aortic aneurysm (AAA). In a prevention strategy, the antagonists were injected before the induction of AAA, and in an intervention strategy, the antagonists were injected after the induction of AAA. Both strategies attenuated the formation of AAA. In the intervention group, BAFF antagonism depleted most of the mature B-cell subsets in spleen and circulation, leading to enhanced resolution of inflammation in AAA as indicated by decreased infiltration of B cells and proinflammatory macrophages and a reduced number of apoptotic cells. In AAA tissues, B cells and macrophages were found in close contact. In vitro, B cells, irrespective of treatment with BAFF, impaired the efferocytosis activity of macrophages, suggesting a direct innate role of B cells on macrophage function. Altogether, BAFF antagonism affects survival of the mature B cells, promotes resolution of inflammation in the aorta, and attenuates the growth of AAA in mice.

Objectives Two trials (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation Trial and Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation Trial) were published in 2018 evaluating the effectiveness and safety of transcatheter repair for patients with heart failure with significant functional mitral regurgitation, which yielded different results. This article reviews the strength of the evidence, differences in trial designs, ethical and implementation implications, and delineates future research needs to help guide the appropriate dissemination of transcatheter repair for functional patients with mitral regurgitation. Methods The National Heart, Lung, and Blood Institute convened a workshop of interdisciplinary experts to address these objectives. Results Transcatheter repair of functional mitral regurgitation can provide significant benefits in terms of heart failure hospitalizations, survival, and quality of life when appropriate heart failure candidates with moderate to severe or severe mitral regurgitation while on optimal guideline-directed medical therapy can be identified. Key ingredients for success are preoperative evaluation and management and postoperative care by an interdisciplinary heart team. Conclusions Given the discordance observed between trials, ongoing innovation in patient management, and potential expansion of indications for use, the evidence base must be expanded to optimize appropriate implementation of this complex therapy. This will require more complete capture of outcome data in real-world settings for all eligible candidates whether or not they receive this therapy. Inevitably, the indications for use of this therapy will expand, as will the devices and therapeutic approaches for this population, necessitating the study of comparative effectiveness through randomized trials or observational studies. Moreover, given the substantial variations in care delivery, conducting implementation research to delineate characteristics of the optimal care model would be of benefit.

Background Patient prosthesis mismatch is associated with significant long-term morbidity and mortality after aortic valve replacement, but the role and outcomes of annular enlargement (AE) remain poorly defined. We hypothesized that increasing rates of AE may lead to improved outcomes for patients at risk for severe patient prosthesis mismatch. Methods Patients over age 65 years undergoing surgical aortic valve replacement with or without coronary artery bypass grafting from 2008-2016 in The Society of Thoracic Surgeons Adult Cardiac Surgery Database with matching Centers for Medicare & Medicaid Services data were included (n=189,268). Univariate, multivariate, and time-to-event analysis was used to evaluate the association between AE and early and late outcomes. Patients were stratified by projected degree of patient prosthesis mismatch based on calculated effective orifice area index. Results A total of 5412 (2.9%) patients underwent AE. The Society of Thoracic Surgeons Adult Cardiac Surgery Database–predicted mortality was similar between AE and non-AE groups (2.97% vs 2.99%, P = .052). Patients undergoing AE had higher risk-adjusted rates of 30-day complications and death (5.4% vs 3.4%, P Conclusions These data suggest that annular enlargement during surgical aortic valve replacement is associated with increased short-term risk in a Medicare population. Survival curves crossed after 3 years, which may portend a benefit in select patients. However, annular enlargement is still only performed in the minority of patients who are at risk for patient prosthesis mismatch.

Background In the absence of randomized controlled trials, reports from nonrandomized studies comparing valve‐in‐valve implantation (ViV) to redo surgical aortic valve replacement (rAVR) have shown inconsistent results. Methods and Results PubMed/MEDLINE, Google Scholar, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched through December 2021. Meta‐Analysis of Observational Studies in Epidemiology guidelines were followed. The protocol was registered at the International Prospective Register of Systematic Reviews. Random effects models were applied. The primary outcomes of interest were short‐term and midterm mortality. Secondary outcomes included stroke, myocardial infarction, acute renal failure, and permanent pacemaker implantation, as well as prosthetic aortic valve regurgitation, mean transvalvular gradient, and severe prosthesis‐patient mismatch. Of 8881 patients included in 15 studies, 4458 (50.2%) underwent ViV and 4423 (49.8%) rAVR. Short‐term mortality was 2.8% in patients undergoing ViV compared with 5.0% in patients undergoing rAVR (risk ratio [RR] 0.55 [95% CI, 0.34–0.91], P =0.02). Midterm mortality did not differ in patients undergoing ViV compared with patients undergoing rAVR (hazard ratio, 1.27 [95% CI, 0.72–2.25]). The rate of acute kidney failure was lower following ViV, (RR, 0.54 [95% CI, 0.33–0.88], P =0.02), whereas prosthetic aortic valve regurgitation (RR, 4.18 [95% CI, 1.88–9.3], P =0.003) as well as severe patient–prothesis mismatch (RR, 3.12 [95% CI, 2.35–4.1], P P =0.008). There were no significant differences between groups with respect to stroke ( P =0.26), myocardial infarction ( P =0.93), or pacemaker implantation ( P =0.21). Conclusions Results of this meta‐analysis demonstrate better short‐term mortality after ViV compared with rAVR. Midterm mortality was similar between groups. Given the likely selection bias in these individual reports, an adequately powered multicenter randomized clinical trial with sufficiently long follow‐up in patients with low‐to‐intermediate surgical risk is warranted. Registration URL: crd.york.ac.uk/prospero/ . Unique identifier: CRD42021228752.

Time-directed extubation (fast-track) protocols may decrease length of stay and cost but data on operating room (OR) extubation is limited. The objective of this study was to compare the outcomes of extubation in the OR versus fast-track extubation within 6 hours of leaving the operating room. Patients undergoing nonemergent STS index cases (2011-2021) who were extubated within 6 hours were identified from a regional STS quality collaborative. Patients were stratified by extubation in the OR versus fast track. Propensity score matching (1:n) was performed to balance baseline differences. Of the 24,962 patients, 498 were extubated in the OR. After matching, 487 OR extubation cases and 899 fast track cases were well balanced. The rate of reintubation was higher for patients extubated in the OR [21/487 (4.3%) vs 16/899 (1.8%), P = 0.008] as was the incidence of reoperation for bleeding [12/487 (2.5%) vs 8/899 (0.9%), P = 0.03]. There was no significant difference in the rate of any reoperation [16/487 (3.3%) vs 15/899 (1.6%), P = 0.06] or operative mortality [4/487 (0.8%) vs 6/899 (0.6%), P = 0.7]. OR extubation was associated with shorter hospital length of stay (5.6 vs 6.2 days, P0.001) and lower total cost of admission ($29,602 vs $31,565 P0.001). OR extubation is associated with a higher postoperative risk of reintubation and reoperation due to bleeding, but lower resource utilization.Future research exploring predictors of extubation readiness may be required prior to widespread adoption of this practice.

Health Professional Shortage Areas (HPSA) were created by the Health Resources and Services Administration to identify communities with a shortage of clinical providers. For medical conditions, these designations are associated with worse outcomes. However, far less is known about patients undergoing high complexity surgical procedures, such as coronary artery bypass grafting (CABG).To compare post-operative surgical outcomes of high complexity surgery in beneficiaries living in HPSA versus non-HPSA designated areas.This study is a retrospective cohort review of Medicare beneficiaries who underwent CABG between 2014-2018. We compared risk-adjusted 30-day mortality, complication, reoperation, and readmission rates for beneficiaries living in a designated HPSA versus non-HPSA using a multivariable logistic regression model accounting for patient (e.g., age, sex, comorbidities, surgery year) and hospital characteristics (e.g., patient-to-nurse ratio, teaching status). Patient travel burden was measured based on the time and distance required to travel from the beneficiary's home zip code to the hospital zip code.Of the 370,532 Medicare beneficiaries who underwent CABG, 30,881 (8.3%) lived in a Health Professional Shortage Area. Beneficiaries in HPSAs were found to experience comparable 30-day mortality (3.50% vs. 3.65%, P0.001), complication (32.67% vs. 33.54%, P0.001), reoperation (1.58% vs. 1.66%, P0.001), and readmission (14.72% vs. 14.86%, P0.001) rates. Beneficiaries experienced greater mean travel times (91.2 minutes vs. 64.0 minutes, P0.001) and mean travel distances (85.0 miles vs. 59.3 miles, P0.001).Medicare beneficiaries living in designated Health Professional Shortage Areas experienced comparable surgical outcomes after coronary artery bypass graft surgery but a significantly greater travel burden. The greater travel burden experienced by patients living in designated shortage areas to obtain comparable surgical care for complex procedures demonstrates important tradeoffs between access and quality.

Objective: The need for concomitant tricuspid surgery during mitral valve surgery is associated with higher operative risk. We hypothesized that concomitant tricuspid surgery through a minimally invasive thoracotomy (MICS) is associated with noninferior risk compared with a sternotomy. Methods: All patients undergoing mitral valve surgery at a single institution (2010 to 2020) were evaluated. After excluding endocarditis, emergent operations, and concomitant aortic valve or coronary artery bypass grafting procedures, patients were stratified by MICS versus sternotomy. Multivariable logistic regression assessed the risk-adjusted association between concomitant tricuspid valve procedure and Society of Thoracic Surgeons major morbidity or mortality. An interaction term evaluated the impact of approach on concomitant tricuspid surgery. Results: A total of 772 patients underwent mitral valve surgery, including 138 (17.9%) with concomitant tricuspid valve operation. Of the total cohort, 243 patients (31.5%) underwent the MICS approach. Concomitant tricuspid operation was performed in 104 sternotomy patients (19.7%) compared with 34 MICS patients (14.0%, P = 0.056). After risk adjustment, patients who underwent concomitant tricuspid valve surgery via sternotomy had nearly 2 times greater odds of morbidity and mortality relative to those undergoing isolated mitral surgery via sternotomy (adjOR = 1.86, P = 0.049), while patients who underwent concomitant tricuspid surgery via the MICS approach had no increased risk of the composite outcome (adjOR = 0.66, P = 0.543), relative to isolated mitral surgery via MICS approach. Conclusions: Concomitant tricuspid surgery at the time of mitral valve surgery carries additional risk in a broad patient population. A minimally invasive approach appears to be safe for selected patients requiring concomitant tricuspid valve surgery.

Transcatheter tricuspid valve replacement (TTVR) is rapidly emerging as a therapeutic option amongst patients with secondary tricuspid regurgitation. Historical data from surgical tricuspid valve replacement (TVR) studies may serve as a benchmark for the development of TTVR trials.The aim of the study was to investigate the early and late outcomes following isolated surgical TVR.Multiple electronic databases were searched to identify studies on isolated surgical TVR. The prespecified primary endpoint was operative mortality; secondary endpoints were early and late outcomes. Overall estimates of proportions and incidence rates with 95% confidence intervals (CI) were calculated using random-effects models. Multiple sensitivity analyses accounting for baseline characteristics, country and the operative period were applied. Results: A total of 35 studies (5,316 patients) were included in this meta-analysis. The operative period ranged from 1974 to 2019. The overall rate of operative mortality was 12% (95% CI: 9-15), with higher mortality for patients who were operated on before 1995, who had prior cardiac surgeries, or who had liver disease. The most frequent clinical events were pacemaker implantation (10% [95% CI: 6-16]), bleeding (12% [95% CI: 8-17]), acute kidney injury (15% [95% CI: 9-24]) and respiratory complications (15% [95% CI: 12-20]). At follow-up analysis of the bioprosthetic TVR, there was an incidence rate per 100 person-years of 6 (95% CI: 2-13) for death and 8 (95% CI: 5-13) for recurrence of significant tricuspid regurgitation.This meta-analysis provides an overview of the historical clinical outcomes following isolated surgical TVR. These findings can support the development of future clinical trials in the tricuspid space by providing thresholds for clinical outcomes.

Objectives The aim of this study was to determine clinical and echocardiographic characteristics, mechanisms of failure, and outcomes of mitral valve (MV) surgery after transcatheter edge-to-edge repair (TEER). Background Although >100,000 mitral TEER procedures have been performed worldwide, longitudinal data on MV surgery after TEER are lacking. Methods Data from the multicenter, international CUTTING-EDGE registry were retrospectively analyzed. Clinical and echocardiographic outcomes were evaluated. Median follow-up duration was 9.0 months (interquartile range [IQR]: 1.2-25.7 months) after MV surgery, and follow-up was 96.1% complete at 30 days and 81.1% complete at 1 year. Results From July 2009 to July 2020, 332 patients across 34 centers underwent MV surgery after TEER. The mean age was 73.8 ± 10.1 years, median Society of Thoracic Surgeons risk for MV repair at initial TEER was 4.0 (IQR: 2.3-7.3), and primary/mixed and secondary mitral regurgitation were present in 59.0% and 38.5%, respectively. The median interval from TEER to surgery was 3.5 months (IQR: 0.5-11.9 months), with overall median Society of Thoracic Surgeons risk of 4.8% for MV replacement (IQR: 2.8%-8.4%). The primary indication for surgery was recurrent mitral regurgitation (33.5%), and MV replacement and concomitant tricuspid surgery were performed in 92.5% and 42.2% of patients, respectively. The 30-day and 1-year mortality rates were 16.6% and 31.3%, respectively. On Kaplan-Meier analysis, the actuarial estimates of mortality were 24.1% at 1 year and 31.7% at 3 years after MV surgery. Conclusions In this first report of the CUTTING-EDGE registry, the mortality and morbidity risks of MV surgery after TEER were not negligible, and only

Transcatheter mitral valve replacement (TMVR) is a new therapy for treating symptomatic mitral regurgitation (MR) and stenosis. The proposed benefit of TMVR is the predictable, complete elimination of MR, which is less certain with transcatheter repair technologies such as TEER (transcatheter edge-to-edge repair). The potential benefit of MR elimination with TMVR needs to be rigorously evaluated against its risks which include relative procedural invasiveness, need for anticoagulation, and chronic structural valve deterioration. Randomized controlled trials (RCTs) are a powerful method for evaluating the safety and effectiveness of TMVR against current standard of care transcatheter therapies, such as TEER. RCTs not only help with the assessment of benefits and risks, but also with policies for determining operator or institutional requirements, resource utilization, and reimbursement. In this paper, the authors provide recommendations and considerations for designing pivotal RCTs for first-in-class TMVR devices.

Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery.All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated.A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission.Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery.

Background Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), there are scant data regarding aortic valve reintervention after initial TAVR. Methods Between 2011 and 2019, 1487 patients underwent a TAVR at the University of Michigan. Among these, 24 (1.6%) patients required an aortic valve reintervention. Additionally, 4 patients who received a TAVR at another institution underwent a valve reintervention at our institution. We retrospectively reviewed these 28 patients. Results The median age was 72 years, 36% were female and 86% of implanted TAVR devices were self-expandable. The leading indications for reintervention were structural valve degeneration (39%) and paravalvular leak (36%). The cumulative incidence of aortic valve reintervention was 4.6% at 8 years. Most (71%) were deemed unsuitable for repeat TAVR because of the need for concurrent cardiac procedures (50%), unfavorable anatomy (45%), or endocarditis (10%). TAVR valve explant was associated with frequent concurrent procedures, consisting of aortic repair (35%), mitral repair/replacement (35%), tricuspid repair (25%), and coronary artery bypass graft (20%). Seventy-one percent of aortic procedures were unplanned but proved necessary because of severe adhesion of the devices to the contacting tissue. There were 3 (15%) in-hospital mortalities in the TAVR valve explant group, whereas there was no mortality in the repeat TAVR group. Conclusions Repeat TAVR procedure was frequently not feasible because of unfavorable anatomy and/or the need for concurrent cardiac procedures. Careful assessment of TAVR procedure repeatability should be weighed at the initial TAVR workup especially in younger patients who are expected to require a valve reintervention.

Background Alpha-gal syndrome is a tick-acquired disease caused by immunoglobulin E (IgE) to the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal), causing allergic reactions to meat and products sourced from nonprimate mammals. As heparin is porcine-derived, we hypothesized that patients with alpha-gal syndrome who received high-dose heparin for cardiac surgery would have increased risk of anaphylaxis. Methods All cardiac surgery patients at an academic medical center from 2007 to 2019 were cross-referenced with research and clinical databases for the alpha-gal IgE blood test. Clinical data were obtained through the institutional Society of Thoracic Surgeons Adult Cardiac Database and chart review. Patients were stratified by development of an allergic reaction for univariate statistical analysis. Results Of the 8819 patients, 17 (0.19%) had a positive alpha-gal test before cardiac surgery. Of these 17 patients, 4 (24%) had a severe allergic reaction. The median alpha-gal titer was significantly higher in patients with a reaction (75 [interquartile range, 61-96] IU/mL vs 8 [interquartile range, 3-18] IU/mL; P = .006). There were no differences in median heparin loading dose, total dose, or maximum activated clotting time (all P > .05). In a subgroup of 8 patients with recent alpha-gal IgE level, 4 (50%) developed an allergic reaction. Conclusions Although alpha-gal is rare in patients undergoing cardiac surgery, there is up to a 50% risk of serious allergic reaction to heparin for cardiopulmonary bypass. Higher preoperative alpha-gal titers may confer a higher risk of severe allergic reaction. For patients with a clinical suspicion of alpha-gal syndrome, we recommend prescreening with IgE levels and premedicating before receiving high doses of intravenous heparin.

Background Limited multi-institutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort. Methods Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis. Results Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P = .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P = .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P = .013), and had longer intensive care unit (45 vs 30 hours, P = .049) as well as hospital lengths of stay (7 vs 6 days, P = .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P Conclusions Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.

Transcatheter options for treating significant symptomatic mitral valve regurgitation (MR) have gained a significant role over the past decade in clinical practice. Increasing clinical trial eviden...

Diffuse intimal hyperplasia and graft irregularity adversely affect the long-term patency of saphenous vein grafts (SVGs) and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). The VEST trial evaluated the efficacy of external graft support in limiting the development of intimal hyperplasia (IH) at 1 year postsurgery. In the present secondary analysis, we explored the associations between graft disease and IH and clinical events. We also examined risk factors for early graft occlusion.VEST is a within-patient randomized, multicenter trial that enrolled 224 patients with multivessel coronary disease undergoing CABG surgery, of whom 203 were evaluated by 1 year postsurgery. Intimal hyperplasia, lumen uniformity, graft stenosis, and graft perfusion were measured by intravascular ultrasound and angiography. Major cardiac and cerebrovascular events (MACCE; including death, myocardial infarction, stroke, and revascularization) were recorded over a median follow-up of 3 years.Worse lumen uniformity, greater stenosis, and worse graft perfusion were associated with higher IH values and an increased incidence of clinical events. Consistent with previous findings, we identified endoscopic vein harvesting, female sex, and transit time flow measurement of pulsatility index and flow as risk factors for SVG occlusion during the first year postsurgery.In this secondary analysis of the VEST trial, we observed an association between intimal hyperplasia area and clinical measures of SVG disease at 1 year postsurgery. More severe SVG disease and larger areas of IH were associated with a higher incidence of 3-year MACCE. Ongoing follow-up to 5 years will further elucidate the impact of SVG disease on long-term clinical outcomes of CABG.

Guidelines for choice of replacement valve-mechanical versus bio-prosthetic, are well established for patients aged50 and65 years. We studied the trends and implications of aortic valve replacement (AVR) with mechanical versus bioprosthetic valve in patients aged 50 to 65 years.STS and cost database of 17 centers for isolated AVR surgery were analyzed by dividing them into bioprosthetic valve (BV) or mechanical valve (MV) groups.From 2002 to 2011, 3,690 patients had AVR, 18.6% with MV and 81.4% with BV. Use of BV for all ages increased from 71.5% in 2002 to 87% in 2011. There were 1127 (30.5%) patients in the age group 50-65 years. Use of BV in this group almost doubled, 39.6% in 2002 to 76.8% in 2011. Mean age of patients in BV group was higher (59.2±4.2 years vs. 56.7±4.3 years, P≤0.0001). Preoperative renal failure, heart failure and chronic obstructive pulmonary disease favored use of BV, whereas preoperative atrial fibrillation favored AVR with MV. Mortality (MV 2.2% vs. BV 2.36%) and other postoperative outcomes between the groups were similar. Cost of valve replacement increased for both groups (MV $26,191 in 2002 to $42,592 in 2011; BV $27,404 in 2002 to $44,257 in 2011).Use of bioprostheses for AVR has increased; this change is more pronounced in patients aged 50-65 years. Specific preoperative risk factors influence the choice of valve for AVR. Postoperative outcomes between the two groups were similar. Long-term implications of this changing practice, in particular, reoperation for bioprosthetic valve degeneration should be examined.

Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P = 0.016). High socioeconomic distress (DCI75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis.

Our objective was to compare national mitral repair rates and outcomes after less invasive mitral surgery (LIMS) vs conventional sternotomy across the spectrum of mitral pathologies and repair techniques.Patients undergoing isolated primary mitral valve surgery in The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 2014 to December 2018 were evaluated. Propensity score models were constructed nonparsimoniously, and prediction models used to compute adjusted effects of surgical approach. Hypothesis tests were adjusted for propensity score with inverse-probability weighting.A total of 41,082 patients met inclusion criteria; comprising 10,238 (24.9%) LIMS and 30,844 (75.1%) conventional sternotomy, with increased LIMS adoption annually. Surgeons reporting LIMS cases had higher annual median mitral case volumes than those who did not (23 vs 8, P.001). Groups were well-balanced after propensity adjustment including mitral pathology. Propensity score-adjusted outcomes showed increased procedural volume (odds ratio 1.030 [95% confidence interval: 1.028-1.031]) and LIMS (odds ratio 2.139 [95% confidence interval 2.032-2.251]) were independently associated with higher mitral repair rates. Propensity-adjusted outcomes included reduced stroke (P.001), atrial fibrillation (P.001), pacemaker (P .001), renal failure (P.001), and length of stay (P .001) for LIMS vs sternotomy, without differences in mortality. Operative volume influenced outcomes in both groups.LIMS was associated with higher mitral repair rates, and lower morbidity. Further studies regarding the impact of surgeon volume on choice of operative approach are necessary.

Objective The safety of minimally invasive mitral valve surgery (MIMVS) in elderly patients is still debated. Our objective was to perform a systematic review and meta-analysis of studies comparing MIMVS with conventional sternotomy (CS) in elderly patients (≥65 years old). Methods We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for trials and observational studies comparing MIMVS with CS in patients ≥65 years old presenting for mitral valve surgery. We performed a random-effects meta-analysis of all outcomes. Results The MIMVS group had lower odds of acute renal failure (odds ratio [OR] 0.27; 95% CI 0.10 to 0.78), prolonged intubation (>48 h; OR 0.47; 95% CI 0.31 to 0.70), less blood product transfusion (weighted mean difference [WMD] −0.82 units; 95% CI −1.29 to −0.34 units), shorter ICU length of stay (LOS; WMD −2.57 days; 95% CI −3.24 to −1.90 days) and hospital LOS (WMD −4.06 days; 95% CI −5.19 to −2.94 days). There were no significant differences in the odds of mortality, stroke, respiratory infection, reoperation for bleeding, and postoperative atrial fibrillation. MIMVS was associated with longer cross-clamp (WMD 11.8 min; 95% CI 3.5 to 20.1 min) and cardiopulmonary bypass times (WMD 23.0 min; 95% CI 10.4 to 35.6 min). Conclusions MIMVS in elderly patients is associated with lower postoperative complications, blood transfusion, shorter ICU, and hospital LOS, and longer cross-clamp and bypass times.

BACKGROUND: A significant percentage of patients that acutely develop high-grade atrioventricular block following valve surgery will ultimately recover, yet the ability to predict recovery is limited. OBJECTIVES: The purpose of this analysis was to evaluate the cost effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block following valve surgery. METHODS: A cost effectiveness model was developed using costs and probabilities of short and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow up. We aggregated the total expected cost and utility of each option over a 20 year time period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 days with timing of pacemaker implantation: early placement (5 days) versus watchful waiting for 12 days. RESULTS: A strategy of watchful waiting was more costly ($171,798 ± $45,695 vs $165,436 ± $52,923, p

Objectives In this study we evaluated the clinical characteristics and outcomes of surgically ineligible patients with coronary artery disease (CAD) who underwent multivessel percutaneous coronary intervention (PCI). Background Patients with multivessel CAD who are surgically ineligible and undergo PCI are not well represented in large trials. Methods Out of 1,061 consecutive patients who underwent a non-emergent PCI for unprotected left main or multivessel CAD at the University of Virginia Medical Center, 137 patients were determined to be surgically ineligible for coronary artery bypass graft (CABG) surgery by a heart team. The clinical characteristics and reasons for surgical ineligibility were collected. The coronary angiograms were reviewed and the SYNTAX score calculated. The Society of Thoracic Surgeons (STS) score was calculated. Outcomes were determined at 30 days and 1-year. Results The mean age of the cohort was 71 and 59% were women. Hypertension, hyperlipidemia, tobacco abuse, and diabetes were common comorbidities. The average SYNTAX score was 22. The most commonly cited reasons for surgical ineligibility were advanced age, frailty, severe lung disease, ejection fraction ≤ 30% and STS score ≥ 8%. Outcomes at 30 days were excellent and better than those predicted by STS for surgery. Frailty and STS score predicted one-year outcomes. Conclusions Patients undergoing PCI for multivessel disease who are surgically ineligible have multiple risk factors and comorbidities. Frailty, lung disease, poor left ventricular function, and high STS score represent common reasons for surgical ineligibility. Frailty and the STS score better predict one-year outcomes after PCI compared to the SYNTAX score.

Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).

The long-term implications of tracheostomy in cardiac surgical patients are largely unknown. We sought to investigate outcomes including decannulation and long-term mortality in a population of post-cardiac surgery patients.All patients undergoing cardiac surgery at a single institution between 1997 and 2016 were evaluated for postoperative tracheostomy placement, time to decannulation, and mortality. Patients were stratified by tracheostomy placement, as well as by successful decannulation for comparison. Kaplan-Meier analysis identified time to decannulation and mortality and a Fine-Gray's competing risk regression, accounting for mortality, identified predictors of time to decannulation.Of 14,600 total cardiac surgery patients, only 309 required tracheostomy. Patients with tracheostomy had high rates of perioperative comorbidities, including 60% with heart failure and 24% with postoperative stroke. Tracheostomy patients had high short-term and long-term mortality, with a median survival of 152 days, 1-year survival of 41%, and 5-year survival of 29.1%. Patients remained with tracheostomy in place for a median of 59 days, with a 1-year decannulation rate of 80% in living patients. Patients with older age (hazard ratio 0.98, P = .01), chronic lung disease (hazard ratio 0.66, P = .03), and preoperative or postoperative dialysis (hazard ratio 0.45, P.01) were less likely to have their tracheostomy removed.Tracheostomy is associated with poor long-term survival of cardiac surgery patients. However, patients who do survive have a short duration of tracheostomy with almost all surviving patients eventually decannulated. This finding provides valuable information for pre-procedural counseling for these high-risk patients and their families.

Background Concomitant surgical ablation for atrial fibrillation (AF) at the time of mitral valve surgery is a Society of Thoracic Surgeons Class IA recommendation with evidence from randomized trial data. We hypothesized that concomitant AF ablation rates have increased over time with implementation of this evidence-based practice. Methods All patients (N = 7261) undergoing mitral valve operations (2011-2018) were queried from a regional Society of Thoracic Surgeons database. Patients with preoperative AF were stratified by concomitant AF ablation. Trends in concomitant ablation were evaluated over time as well as by center and surgeon mitral surgical volume. The associations between patient and center factors on implementation of concomitant ablation were assessed with multivariate regression. Results A total of 1675 patients with preoperative AF underwent isolated mitral valve operations, with 1044 (64.6%) undergoing concomitant ablation. The utilization of concomitant ablation decreased over the study period (-2.82%/year), and was strongly associated with surgeon mitral valve volume (high 78.2% vs medium 62.5% vs low 59.0%; P Conclusions Despite increasing evidence and societal recommendations, we demonstrate a persistent underutilization of concomitant AF ablation during isolated mitral surgery across a large number of low-volume and high-volume centers. These data suggest significant variability and may represent an opportunity for improvement.

Tricuspid regurgitation (TR) is associated with poor outcomes after cardiac surgery. Guidelines recommend correction of severe TR in patients undergoing left-sided valve surgery but not coronary artery bypass graft surgery (CABG). We sought to evaluate impact of TR on outcomes after CABG.All patients (n = 28,027) undergoing CABG in The Society of Thoracic Surgeons (STS) regional database (2011 to 2018) were stratified by TR severity. Primary outcomes included major morbidity or mortality, which were compared using univariate analysis.Of patients undergoing CABG, 4837 (17%) had mild, 800 (3%) had moderate, and 81 (0.29%) had severe TR. Increased severity was associated with higher rate of preoperative heart failure (none 5162 [23.4%] vs mild 1697 [35%] vs moderate 427 [53%] vs severe 54 [67%], P.001] and STS predicted risk of mortality (1.0 [0.6 to 1.9) vs 1.4 [0.8 to 2.9] vs 2.8 [1.4 to 5.4] vs 6.2 [2.2 to 11.4], P.001). Increasing severity was associated with higher postoperative rate of renal failure (426 [1.9%] vs 145 [3%] vs 58 [7.3%] vs 7 [8.6%], P.001), prolonged ventilation (1652 [7.5%] vs 495 [10.2%] vs 153 [19.1%] vs 22 [27.2%], P.001), and mortality (344 [1.6%] vs 132 [2.7%] vs 58 [7.3%] vs 9 [11.1%], P.001). After risk adjustment, mild, moderate, and severe TR remained associated with increased morbidity and mortality (all P.05).Increasing TR severity, although independently associated with higher surgical risk, is not accounted for entirely by STS risk calculator. This highlights the importance of TR on operative risk and supports consideration of concurrent tricuspid intervention for patients with significant TR undergoing CABG.

Objective To investigate the impact of limiting the definition of post-coronary artery bypass graft (CABG) atrial fibrillation (AF) to AF/flutter requiring treatment—as in the Society of Thoracic Surgeons' (STS) database— on the association with survival. Patients and Methods We assessed in-hospital incidence of post-CABG AF in 7110 consecutive isolated patients with CABG without preoperative AF at 4 hospitals (January 1, 2004 to December 31, 2010). Patients with ≥1 episode of post-CABG AF detected via continuous in-hospital electrocardiogram (ECG)/telemetry monitoring documented by physicians were assigned to the following: Group 1, identified as having post-CABG AF in STS data and Group 2, not identified as having post-CABG AF in STS data. Patients without documented post-CABG AF constituted Group 3. Survival was compared via a Cox model, adjusted for STS risk of mortality and accounting for site differences. Results Over 7 years’ follow-up, 16.0% (295 of 1841) of Group 1, 18.7% (79 of 422) of Group 2, and 7.9% (382 of 4847) of Group 3 died. Group 2 had a significantly greater adjusted risk of death than both Group 1 (hazard ratio [HR]: 1.16; 95% confidence interval [CI], 1.02 to 1.33) and Group 3 (HR: 1.94; 95% CI, 1.69 to 2.22). Conclusions The statistically significant 16% higher risk of death for patients with AF post-CABG missed vs captured in STS data suggests treatment and postdischarge management should be investigated for differences. The historical misclassification of “missed” patients as experiencing no AF in the STS data weakens the ability to observe differences in risk between patients with and without post-CABG AF. Therefore, STS data should not be used for research examining post-CABG AF.

The prevalence of non-vitamin K oral anticoagulant use after cardiac surgery is unknown, particularly in patients with bioprosthetic valves. We sought to define the contemporary use and short-term safety of non-vitamin K oral anticoagulants after cardiac surgery.All patients undergoing bioprosthetic aortic valve replacement, bioprosthetic mitral valve replacement, or isolated coronary artery bypass grafting (2011-2018) were evaluated from a multicenter, regional Society of Thoracic Surgeons database. Patients were stratified by anticoagulant type (non-vitamin K oral anticoagulant vs vitamin K antagonist) and era (early [2011-2014] vs contemporary [2015-2018]).Of 34,188 patients, 18% (6063) were discharged on anticoagulation, of whom 23% were prescribed non-vitamin K oral anticoagulants. Among those receiving anticoagulation, non-vitamin K oral anticoagulant use has significantly increased from 10.3% to 35.4% in contemporary practice (P .01). This trend was observed for each operation type (coronary artery bypass grafting 0.86%/year, bioprosthetic aortic valve replacement: 2.15%/year, bioprosthetic mitral valve replacement: 2.72%/year, all P .01). In patients with postoperative atrial fibrillation receiving anticoagulation, non-vitamin K oral anticoagulant use has increased from 6.3% to 35.4% and 12.3% to 40.3% after bioprosthetic valve replacement and isolated coronary artery bypass grafting, respectively (both P .01). In patients receiving anticoagulation at discharge, adjusted 30-day mortality (odds ratio, 1.94; P = .12) and reoperation (odds ratio, 0.79; P = .34) rates were not associated with anticoagulant choice, whereas non-vitamin K oral anticoagulant use was associated with an adjusted 0.9-day decrease (P .01) in postoperative length of stay.Non-vitamin K oral anticoagulant use after cardiac surgery has dramatically increased since 2011. This trend is consistent regardless of indication for anticoagulation including bioprosthetic valves. Short-term outcomes support their safety in the cardiac surgery setting with shorter postoperative hospital stays. Long-term studies on the efficacy of non-vitamin K oral anticoagulants after cardiac surgery are still necessary.