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Population-level data are limited regarding contemporary practice and outcomes of isolated tricuspid operations. We evaluated this using The Society of Thoracic Surgeons Adult Cardiac Surgery Database. We identified 14,704 isolated tricuspid operations from The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 1, 2011 to June 30, 2020. After excluding patients with endocarditis, tricuspid stenosis, emergent/emergent salvage status, previous heart transplants, and missing tricuspid operation type, 6507 patients remained. Endpoints were operative mortality and composite major comorbidities (permanent stroke, renal failure, prolonged ventilation > 24 hours, deep sternal wound infection, cardiac reoperations, and new permanent pacemaker implantation). Isolated tricuspid operations increased from 2012 (983 cases) to 2019 (2155 cases, P <.001). Median annual center volume was 2 cases (range, 1-81). In the final cohort (n = 6507; median age, 65 years; 38.5% men), 40% had New York Heart Association class III/IV heart failure and 24% had nonelective operations. The operative mortality was 7.3% (1.7% in patients without these risk factors), and new permanent pacemaker implant rate was 10.8%. In the multivariable analysis, factors associated with operative mortality included New York Heart Association class III/IV heart failure (odds ratio [OR], 1.57), nonelective operations (OR, 1.91), tricuspid replacement (OR, 1.56), annual center volume ≤ 5 cases (OR, 1.37), and higher model for end-stage liver disease scores (all P <.05). Beating heart operation was associated with a lower adjusted risk of pacemaker implant (OR, 0.69), renal failure (OR, 0.75), and blood transfusions (OR, 0.8) compared with full cardioplegic arrest (all P <.05). Isolated tricuspid repair was associated with lower adjusted mortality and morbidities than replacement. Beating heart operation was associated with lower adjusted major morbidities. The preoperative model for end-stage liver disease scores may identify high-risk patients, and early referral to higher volume centers may help improve outcomes. [Display omitted] [ABSTRACT FROM AUTHOR]

Variation in degenerative mitral morphology may contribute to suboptimal repair rates. This study evaluates outcomes of a standardized mitral repair technique. An institutional clinical registry was used to identify 1036 consecutive patients undergoing robotic mitral surgery between 2005 and 2020: 87% (n = 902) had degenerative disease. Calcification, failed transcatheter repair, and endocarditis were excluded, leaving 582 (68%) patients with isolated posterior leaflet and 268 (32%) with anterior or bileaflet prolapse. Standardized repair comprised triangular resection and true-sized flexible band in posterior leaflet prolapse. Freedom from greater than 2+ moderate mitral regurgitation stratified by prolapse location was assessed using competing risk analysis with death as a competing event. Median follow-up was 5.5 (range 0-15) years. Of patients with isolated posterior leaflet prolapse, 87% (n = 506) had standardized repairs and 13% (n = 76) had additional or nonresectional techniques vs 24% (n = 65) and 76% (n = 203), respectively, for anterior or bileaflet prolapse (P <.001). Adjunctive techniques in the isolated posterior leaflet group included chordal reconstruction (8.6%, n = 50) and commissural sutures (3.4%, n = 20). Overall, median clamp time was 80 (interquartile range, 68-98) minutes, 17 patients required intraoperative re-repair, and 6 required mitral replacement. Freedom from greater than 2+ regurgitation or reintervention at 10 years was 92% for posterior prolapse (vs 83% for anterior or bileaflet prolapse). Anterior or bileaflet prolapse was associated with late greater than 2+ regurgitation (hazard ratio, 3.0; 95% confidence interval, 1.3-7.0). Posterior leaflet prolapse may be repaired in greater than 99% of patients using triangular resection and band annuloplasty, with satisfactory long-term durability. Increased risk of complex repairs and inferior durability highlights the value of identifying anterior and bileaflet prolapse preoperatively. [ABSTRACT FROM AUTHOR]

Mitral valve repair is infrequently performed in patients undergoing corrective surgery for failed mitral transcatheter edge-to-edge repair in current United States practice. This article describes surgical techniques for reconstructive surgery after failed transcatheter edge-to-edge repair. Nine patients underwent robotic-assisted mitral surgery after failed transcatheter edge-to-edge repair between 2008 and 2020 at a single center. Repair was completed in 88.9% (n = 8) patients, and freedom from >2+ mitral regurgitation was 87.5% (n = 7) at a median follow-up of 1.9 years. [ABSTRACT FROM AUTHOR]

Acutely decompensated heart failure presents a complicated challenge. Established temporary support measures have significant adverse effects. A minimally invasive temporary left ventricular assist device (LVAD), the Impella 5.0 (Abiomed, Danvers, MA), has been developed to support these patients. Patients with acutely decompensated heart failure in whom medical management had failed and who required additional support using an Impella 5.0 device were evaluated from January 2014 to September 2018 at a single center in a retrospective manner using a prospectively maintained database. Patients were treated with the device as a bridge to recovery (BTR; n = 30), bridge to durable device (BTDD; n = 23), or bridge to transplantation (BTT; n = 47). All devices were placed using an axillary artery approach. Demographic features and outcomes were evaluated for each group and compared. A total of 100 patients underwent insertion of an axillary Impella 5.0 LVAD. Patients had an average age of 56.7 ± 13.2 years, were predominantly male (84%), and had a severely depressed left ventricular ejection fraction (average 16%), and most had an Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 (57%) or 2 (33%) score. When divided into groups, there was no difference in age or INTERMACS score, but a statistical difference was noted in baseline left ventricular ejection fraction (20%, 14%, 15%) and creatinine level (1.0, 2.0, 1.6), in the BTR, BTDD, or BTT group, respectively (all P <.05). Survival was 64% overall, and it was 50%, 48%, and 81% for BTR, BTDD, and BTT, respectively (P =.007). Survival improved during this experience and was 90% overall in the most recent 30 patients. Use of this minimally invasive LVAD system is an attractive strategy to support patients with acute decompensated heart failure to recovery, durable LVAD, or heart transplantation. [ABSTRACT FROM AUTHOR]

Background The Placement of Aortic Transcatheter Valves 2A (PARTNER-2A) randomized trial compared outcomes of transfemoral transcatheter and surgical aortic valve replacement (SAVR) in intermediate-risk patients with severe aortic stenosis. The purpose of the present study was to perform an in-depth analysis of outcomes after SAVR in the PARTNER-2A trial. Methods From January 2012 to January 2014, 937 patients underwent SAVR at 57 centers. Mean age was 82 ± 6.7 years and 55% were men. Less-invasive operations were performed in 140 patients (15%) and concomitant procedures in 198 patients (21%). Major outcomes and echocardiograms were adjudicated by an independent events committee. Follow-up was 94% complete to 2 years. Results Operative mortality was 4.1% (n = 38, Society of Thoracic Surgeons predicted risk of mortality: 5.2% ± 2.3%), observed to expected ratio (O/E) was 0.8, and in-hospital stroke was 5.4% (n = 51), twice expected. Aortic clamp and bypass times were 75 ± 30 minutes and 104 ± 46 minutes, respectively. Patients having severe prosthesis–patient mismatch (n = 260, 33%) had similar survival to patients without ( p > 0.9), as did patients undergoing less-invasive SAVR ( p = 0.3). Risk factors for death included cachexia ( p = 0.004), tricuspid regurgitation ( p = 0.01), coronary artery disease ( p = 0.02), preoperative atrial fibrillation ( p = 0.001), higher white blood cell count ( p < 0.0001), and lower hemoglobin ( p = 0.0002). Conclusions In this adjudicated prospective study, SAVR in intermediate-risk patients had excellent results at 2 years. However, there were more in-hospital strokes than expected, most likely attributable to mandatory neurologic assessment after the procedure. No pronounced structural valve deterioration was found during 2-year follow-up. Continued long-term surveillance remains important. [ABSTRACT FROM AUTHOR]

Background Vasoplegia is characterized as a severe vasodilatory shock after cardiac surgery, and can be associated with substantial morbidity. Increased systemic inflammation and endothelial dysfunction, often related to prolonged cardiopulmonary bypass times, anesthesia, or mechanical circulatory support have been shown to be associated with the development of vasoplegia. We sought to identify risk factors and the impact of various degrees of vasoplegia after heart transplantation. Methods A retrospective review was conducted of 244 consecutive patients who underwent heart transplantation over a 3-year period. Patients were divided into three groups: no vasoplegia, mild vasoplegia (requiring one vasopressor), and moderate/severe vasoplegia (more than two vasopressors). One-year survival, freedom from rejection, and postoperative complication rates were assessed. Risk factors for vasoplegia subgroups were retrospectively identified. Results Vasoplegia syndrome was observed in 34.3% of patients after heart transplantation (mild, 74.1%; moderate/severe, 25.9%). Cardiopulmonary bypass time was significantly longer and pretransplant creatinine was significantly higher in the moderate/severe vasoplegia group. There was a strong trend toward greater use of mechanical circulatory support among moderate/severe vasoplegia patients compared with mild and no vasoplegia patients. After heart transplantation, 1-year survival, freedom from rejection, and need for hemodialysis were not significantly different between groups. Conclusions Vasoplegia syndrome is common after heart transplantation. Risk factors for increased severity include longer cardiopulmonary bypass times and elevated preoperative creatinine. Although higher rates of mortality or graft rejection were not detected, vasoplegia was associated with prolonged intubation, greater blood product usage, and lengthened hospital stay. Further studies involving larger cohorts are warranted. [ABSTRACT FROM AUTHOR]

Background: Reports of cardiac surgery in the elderly have focused primarily on septuagenarians and octogenarians. There are very limited data regarding risk-adjusted models in nonagenarians. Methods: From 1983 to 2011, patients with age 90 years or greater at the time of coronary artery bypass grafting (CABG) or valve surgery (aortic or mitral) were retrieved from a prospective institutional database. A Cox proportional hazard model was used to determine significant predictors of 5-year survival. In addition, a 12-month assessment of quality of life was conducted. Results: The CABG-only (n = 46), valve-only (n = 55), or CABG-valve (n = 53) surgery was conducted in 154 patients. Demographic characteristics were similar in all groups except for congestive heart failure, which was more prominent in the valve-only or CABG-valve groups (p < 0.0001). The 30-day mortality was 8.8%, 12.8%, and 18.9% in the CABG-only, valve-only, and CABG-valve groups, respectively, without significant difference among groups (p = 0.35). At 5-years follow-up, the Kaplan-Meier survival curves do not show a difference among groups (p = 0.62). Cox proportional hazard model for 5-year survival identified age (hazard ratio [HR] = 1.25, confidence interval [CI] 1.09 to 1.43, p = 0.001, for 1-year increase), prior surgery (HR = 2.23, CI 1.23 to 4.64, p = 0.007), and prior stroke (HR = 2.39, CI 1.25 to 3.98, p = 0.01), as significant predictors of mortality. The 12-month quality of life questionnaire revealed an improvement in 83% of the patients, whereas only 4% reported a decline in cardiac status. Conclusions: Survival in nonagenarians is comparable after CABG or valve surgery. Redo surgery, stroke, and increasing age are significant hazards for mortality. Nonagenarians can undergo cardiac surgery with acceptable mortality and quality of life. [ABSTRACT FROM AUTHOR]

Background: Heart transplantation for sensitized patients has been a significant challenge. In this study, outcome of heart transplantation in sensitized patients with virtual cross match was compared with prospective cross match. Methods: Prior to July 2007, prospective cross match was used and afterward, virtual cross match with Luminex (One Lambda, Inc, Canoga Park, CA) based antibody analysis was used for potential heart transplant recipients. Prospectively collected data for the 3 years before and after July 2007, in sensitized (panel reactive antibody greater than 10%) and nonsensitized heart transplant recipients were reviewed. Results: One hundred sixty-eight patients met inclusion criteria for analysis (78 patients for prospective cross match and 90 patients for virtual cross match). Multiple parameters were compared for the prospective cross match and virtual cross match eras. Three-year survivals in nonsensitized patients were 84.6% and 77.2% and in sensitized patients were 76.9% and 77.4% (p = 0.49) for prospective cross match and virtual cross match eras, respectively. Freedom from 3A (2R) cellular rejection in nonsensitized patients was 96.9% and 95.3%, and in sensitized patients was 90.9% and 100% (p = 0.83). Freedom from antibody-mediated rejection in nonsensitized patients was 95.3% and 96.8%, and in sensitized patients was 90.9% and 90.5% (p = 0.65). Mean waiting time was 129 ± 246 days (mean ± SD) for the period before virtual cross match and 59 ± 78 days with virtual cross match (p = 0.018). Donor geographic area was similar for prospective and virtual cross match. Conclusions: In sensitized heart transplant candidates, virtual cross match may shorten waiting time to heart transplantation without increasing subsequent occurrence of cellular rejection, antibody mediated rejection, and mortality after heart transplantation. [Copyright &y& Elsevier]

Background: We aimed to determine the risk factors associated with mortality in patients with congenitally bicuspid aortic valve disease and dilation (<5 cm) of the ascending aorta after aortic valve replacement. Methods: We reviewed 252 patients with bicuspid aortic valve undergoing aortic valve replacement at our institution from 1971 through 2000. Patients undergoing concomitant replacement of the ascending aorta were excluded. Results: The average patient age was 61 ± 15 years; 66.3% were male, and 40.5% of patients had coronary artery disease. The ascending aorta was normal (<4.0 cm) in 60.3%, mildly dilated (4.0 to 4.4 cm) in 24.2%, and moderately dilated (4.5 to 4.9 cm) in 15.5% of patients. Patients with moderate aortic dilatation had significantly lower prevalence of coronary artery disease compared with patients with normal ascending aortas (20.5% and 45.4%; p = 0.006). Mean follow-up was 8.9 ± 6.3 years. Long-term survival was significantly different across the three groups (p = 0.004). The 5-, 10-, and 15-year estimates were 78%, 59%, and 37%, respectively, in the normal aorta group; 88%, 77%, and 46%, respectively, in the mild aortic dilation group; and 92%, 83%, and 70%, respectively, in the moderate aortic dilation group. No significant difference in cardiac death was found among the groups (p = 0.08). The significant predictors of survival using the Cox regression model were coronary artery disease, age, decade of surgery, and ejection fraction. Aortic dilation was not significant after adjusting for these other variables. At follow-up, 18 patients required reoperation, 17 for aortic valve prosthesis failure and 1 for ascending aorta aneurysm. Conclusions: The present study highlights the important adverse effect of concomitant coronary artery disease, advanced age, earlier decade of surgery, and reduced left ventricular ejection fraction on survival after aortic valve replacement for bicuspid aortic valve in patients with no or mild and moderate (<5 cm) dilation of the ascending aorta. [Copyright &y& Elsevier]

Background: In this study we compared the surgical management of ischemic mitral regurgitation (IMR) by revascularization alone and by revascularization combined with mitral valve repair. Methods: We studied 355 patients who underwent revascularization alone (n = 168) or revascularization combined with mitral valve repair (n = 187) for IMR from March 1994 to September 2003. Preoperative and operative characteristics, postoperative mitral regurgitation severity, operative mortality, and late survival were examined for each surgical group. Results: No differences were noted between the two groups in age, sex, history of diabetes or hypertension, and number of bypass grafts. The combined surgical group had a lower preoperative left ventricular ejection fraction (0.38 ± 0.14 versus 0.44 ± 0.15), greater severity of IMR, higher frequency of prior myocardial infarction, and longer cross-clamp and pump times (p &#60; 0.01). The combined surgical group had a greater reduction in IMR grade (2.7 ± 0.1 grades versus 0.2 ± 0.1 grade), a lower postoperative IMR grade (0.9 ± 0.1 versus 2.3 ± 0.1), and a higher success with reduction of IMR by two or more grades (89% versus 11%) (p &#60; 0.001). In patients with 3+ or 4+ IMR, both groups had similar operative mortality (11.0% in the combined group compared with 4.7% for revascularization alone, p = 0.11) and actuarial survival at 5 years (44% ± 5% versus 41% ± 7%, p = 0.53). Independently predictive of higher early mortality (≤30 days) by Cox analysis were longer pump time (p &#60; 0.001) and older age (p &#60; 0.02). Predictive of late mortality (>30 days) were older age (p &#60; 0.001), fewer bypass grafts (p &#60; 0.01), and lower ejection fraction (p &#60; 0.01). After adjustment for these variables, there was a trend (p = 0.08) toward a higher late survival with the combined surgical procedure. Conclusions: In patients with IMR, combined mitral valve repair and revascularization resulted in less postoperative mitral regurgitation and similar 5-year survival when compared with revascularization alone. Attempts to reduce pump time by using off-pump techniques may reduce early mortality in these high-risk patients. [Copyright &y& Elsevier]

Surgical management of intracardiac tumors arising in the inferior vena cava often requires total circulatory arrest for safe and adequate resection. Total circulatory arrest has traditionally been accomplished by accessing the great vessels through a sternotomy. Combination of a sternotomy and a large abdominal incision results in excellent exposure but also creates the potential for significant morbidity. We report here the resection of cavoatrial tumors by achieving total circulatory arrest through femoral arterial and venous cannulation without requiring a sternotomy. This minimal-access total circulatory approach has the potential to greatly diminish morbidity when managing tumors of the inferior vena cava. [Copyright &y& Elsevier]

Background: The association between the severity of arteriosclerosis in the thoracic aorta in patients with isolated aortic stenosis (AS) and with concomitant coronary artery disease (CAD) has been not evaluated. Therefore, the aim of our study was to compare the thoracic aortic atheroma extent and severity in patients with severe AS alone and with concomitant CAD by intraoperative transesophageal echocardiography., Methods: We retrospectively evaluated echocardiograms of 105 consecutive patients with severe degenerative AS who underwent aortic valve replacement. Sixty patients had concomitant CAD (AS/CAD) on coronary angiography and 45 had no CAD (AS alone). These patients were compared with 54 sex- and age-matched patients without AS or CAD. Aortic atheroma (localized intimal thickening of >3 mm) prevalence and morphology in three segments of aorta were assessed with echocardiography., Results: There were 62 men, mean age 75.3 +/- 9.4 years. No difference was observed in age, sex, and risk factors for arteriosclerosis other than hypercholesterolemia among AS/CAD, AS alone, and control groups (88%, 67%, 41%, respectively; p < 0.0001). The AS/CAD group had a significantly higher rate of aortic root calcification (68%, 36%, 26%, respectively; p < 0.0001) and aortic atheroma (ascending aorta [26%, 20%, 14%, respectively; p = 0.03]; aortic arch [78%, 36%, 30%, respectively; p < 0.0001]; descending aorta [72%, 42%, 29%, respectively; p < 0.0001]) than AS alone or control subjects. Patients with AS/CAD also had more complex atheromas in the aortic arch (48%, 20%, 7%, respectively; p < 0.0001). Significant differences in extension of aortic arteriosclerosis (presence of plaques in two or three segments) were observed among the groups (70%, 31%, 18%, respectively; p < 0.0001)., Conclusions: Patients with severe AS and coexisting CAD have more extensive arteriosclerotic changes in the thoracic aorta compared with those with AS alone and control subjects. Preoperative evaluation of the thoracic aorta and more aggressive lipid therapy should be considered in these patients.