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Background Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined. Objectives This study evaluated national outcomes of mitral surgery after TEER. Methods The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality. Results In the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease. Conclusions This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.

Background Despite recent guideline statements, there is still wide practice variation in the use of multiple arterial grafts (MAGs) versus single arterial grafts (SAGs) for patients with multivessel disease undergoing coronary artery bypass graft surgery. This may be related to differences in findings between observational and randomized controlled studies. Objectives This study sought to compare intermediate-term MAG and SAG outcomes with enhanced matching to reduce selection bias. Methods New York’s cardiac registry identified 63,402 multivessel disease patients undergoing coronary artery bypass graft surgery between January 1, 2005, and December 31, 2014, to compare outcomes (median follow-up 6.5 years) for patients receiving SAGs and MAGs. SAG and MAG patients were propensity matched using 38 baseline characteristics to reduce selection bias. The primary endpoint was mortality, and secondary endpoints included repeat revascularization and a composite endpoint of mortality, acute myocardial infarction, and stroke. Results Before matching, 20% of procedures employed MAG. At 1 year, there was no mortality difference between matched MAG and SAG patients (2.4% vs. 2.2%, adjusted hazard ratio [AHR]: 1.11; 95% confidence interval [CI]: 0.93 to 1.32). At 7 years, MAG patients had lower mortality (12.7% vs. 14.3%, AHR: 0.86; 95% CI: 0.79 to 0.93), a lower composite outcome (20.2% vs. 22.8%, AHR: 0.88; 95% CI: 0.83 to 0.93), and a lower repeat revascularization rate (11.7% vs. 14.6%, AHR: 0.80; 95% CI: 0.74 to 0.87). At 7 years, the subgroups for which MAG did not have a lower mortality rate included patients with off-pump surgery, 2-vessel disease with right coronary artery disease, recent acute myocardial infarction, renal dysfunction, and patient ≥70 years of age. Conclusions Mortality and the composite outcome were similar between MAG and SAG patients at 1 year, but lower for MAG after 7 years. Patients of higher volume MAG surgeons experienced lower MAG mortality.

Background Patients with isolated tricuspid regurgitation (TR) in the absence of left-sided valvular dysfunction are often managed nonoperatively. Objectives The purpose of this study was to assess the impact of surgery for isolated TR, comparing survival for isolated severe TR patients who underwent surgery with those who did not. Methods A longitudinal echocardiography database was used to perform a retrospective analysis of 3,276 adult patients with isolated severe TR from November 2001 to March 2016. All-cause mortality for patients who underwent surgery versus those who did not was analyzed in the entire cohort and in a propensity-matched sample. To assess the possibility of immortal time bias, the analysis was performed considering time from diagnosis to surgery as a time-dependent covariate. Results Of 3,276 patients with isolated severe TR, 171 (5%) underwent tricuspid valve surgery, including 143 (84%) repairs and 28 (16%) replacements. The remaining 3,105 (95%) patients were medically managed. When considering surgery as a time-dependent covariate in a propensity-matched sample, there was no difference in overall survival between patients who received medical versus surgical therapy (hazard ratio: 1.34; 95% confidence interval: 0.78 to 2.30; p = 0.288). In the subgroup that underwent surgery, there was no difference in survival between tricuspid repair versus replacement (hazard ratio: 1.53; 95% confidence interval: 0.74 to 3.17; p = 0.254). Conclusions In patients with isolated severe TR, surgery is not associated with improved long-term survival compared to medical management alone after accounting for immortal time bias.

Glenn N. Levine, MD, FACC, FAHA, Chair Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair [††][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, MS, PharmD, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD

The International Registry of Acute Aortic Dissection (IRAD) previously showed a longitudinal trend of decreasing in-hospital and 5 year post discharge mortality of Type B acute aortic dissection (TBAAD). However, this decline was not observed among the subgroup of TBAAD receiving endovascular

Randomized clinical trials of direct oral anticoagulants (DOAC) vs. warfarin in non-valvular atrial fibrillation (NVAF) excluded individuals with post-cardiac surgery atrial fibrillation. We sought to compare short-term outcomes with DOACs vs. warfarin for new onset post-cardiac surgery NVAF.

With improvements in care, an increasing number of patients with coarctation of the aorta (CoA) are surviving into adulthood. Little is known about the management of late complications in adulthood. A retrospective study of 115 adult patients with a history of CoA was performed at a single

This multisocietal Expert Consensus Systems of Care document was commissioned by the American Association for Thoracic Surgery (AATS), the American College of Cardiology (ACC), the Society for Cardiovascular Angiography and Interventions (SCAI), and the Society of Thoracic Surgeons (STS). Expert

The medical profession should play a central role in evaluating evidence related to drugs, devices, and procedures for detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve

Eric S. Williams, MD, MACC, Chair Jonathan L. Halperin, MD, FACC, Co-Chair James A. Arrighi, MD, FACC Eric H. Awtry, MD, FACC Eric R. Bates, MD, FACC Salvatore Costa, MD, FACC Lori Daniels, MD, FACC Akshay Desai, MD, FACC Douglas E. Drachman, MD, FACC Susan Fernandes, LPD, PA-C Rosario

Recent studies have demonstrated that many patients with acute type A aortic dissection (AD) have aortic diameters of 55 mm at presentation, prompting discussion of lowering the prophylactic surgical guidelines. However, risk of dissection at these smaller diameters is poorly defined.The purpose of this study is to understand the risk of AD in moderately dilated ascending aortas using a large echocardiographic data set.Using an institutional echocardiography database, we identified 4,654 nonsyndromic adults (age: 68.6 ± 13.1 years; 1,003 women) with maximal ascending aortic diameters of 40 to 55 mm. We performed competing risk analysis to determine the independent risk factors of AD or aortic rupture.Five hundred eighty-six individuals (12.6%) had bicuspid aortic valves (BAVs). During follow-up (14,431.5 patient-years), AD and rupture occurred in 13 and 1 patients, respectively, which demonstrated a linearized incidence of AD and/or rupture of 0.1% per patient-year. Elective ascending aortic repair was performed in 176 individuals. On multivariable analyses, independent predictors of AD and/or rupture were age (hazard ratio [HR]: 1.06; 95% confidence interval [CI]: 1.01 to 1.12; p= 0.024) and baseline aortic diameters (HR: 1.20; 95% CI: 1.05 to 1.36; p = 0.006). The presence of a BAV was not a significant factor (HR: 0.94; 95% CI: 0.10 to 8.40; p = 0.95). Estimated risks of AD and/or rupture within 5 years were 0.4%, 1.1%, and 2.9% at baseline aortic diameters of 45, 50, and 55 mm, respectively.Risks of AD and/or rupture were significantly correlated with the aortic diameter and age in patients with moderately dilated ascending aortas. However, the risks were low for diameters 5.0 cm when timely elective aortic repair was performed, regardless of the morphology of the aortic valve.

Objectives We sought to define thromboembolic risk after surgery for mitral regurgitation (MR), particularly ischemic stroke (IS) compared with the general population. Background Guidelines recommend surgery in asymptomatic patients with MR, but IS risks are unknown. Methods In 1,344 patients (age 65 ± 12 years) consecutively operated for MR (procedures: 897 mitral valve repair [MRep] and 447 valve replacement: 231 mechanical mitral valve replacement [MVRm], 216 biological mitral valve replacement [MVRb]), thromboembolic complications, particularly IS (diagnosed by neurologists), during follow-up were assessed early ( Results Ischemic stroke occurred in 130 patients: 1.9 ± 0.4% and 2.7 ± 0.5% at 30 days and 180 days, respectively, and 8.1 ± 0.8% at 5 years. We found that IS rates were lowest after MRep versus MVRb and MVRm (6.1 ± 0.9% vs. 8 ± 2.1%, and 16.1 ± 2.7% at 5 years, respectively, p 0.10 between procedures) and moderate risk at >30 days (risk ratio 1.7 overall; 1.3 for MRep; 0.98 for MVRb; 4.8 for MVRm). Beyond 180 days, IS risk declined further and was similar to the population for MRep (relative risk 1.2) and for MVRb (relative risk 0.9). Bleeding risk >30 days was lowest in MRep versus MVRb and MVRm (10-year risk 7 ± 1%, 14 ± 4%, and 16 ± 3%, respectively). Conclusions Thromboembolic complications after MR surgery are a reason for both concern and encouragement. The risk of IS is notable early, irrespective of procedure, but in the long term it is not greater than in the population after MRep and MVRb. Preference for MRep should be emphasized, and trials aiming at preventing IS should be conducted to reduce thromboembolic and hemorrhagic risk after surgery for MR.

Objectives We sought to examine temporal trends in the utilization of coronary revascularization in a geographically defined population. Background Earlier reports on revascularization utilization focused on inpatient settings and did not distinguish incident from recurrent procedures. Furthermore, little is known on age- and gender-specific trends. Finally, longitudinal data on the utilization and results of coronary angiography as explanatory factors for the changing revascularization practice are lacking. Methods Data integrating diagnostic and therapeutic coronary procedures performed in Olmsted County (Minnesota) between 1990 and 2004 were analyzed. Standardized rates were calculated applying the direct method and temporal trends compared using Poisson regression models. Results Revascularization utilization increased by 24% during the study (95% confidence interval [CI] 5% to 46%), but the trends diverged by procedure type, with a sustained increase (69%, 95% CI 43% to 101%) for percutaneous coronary interventions (PCI) contrasting with a stabilization, then decline (−33%, 95% CI −16% to −47%) for coronary artery bypass grafting (CABG). For PCI, although the use increased in all categories, greater increases were noted in the elderly, in women, and for recurrent procedures. No such patterns were detected for CABG. Angiography use remained stable, and the rate of 3-vessel and/or left main disease declined (−22%, 95% CI −8% to −33%). Conclusions Over the 15-year period, revascularization increased in the community with a large increase in PCI partially offset by a decrease in CABG. More PCIs are performed in women and the elderly and for recurrent disease. These changes occurred within the context of a decline in multivessel disease and thus likely reflect the natural history of coronary artery disease.

1.1 Document Development Process #### 1.1.1 Writing Committee Organization The writing committee was selected to represent the American College of Cardiology (ACC) and included a cardiovascular training program director; a director of a coronary care unit; experts in advanced interventional

Background: Residual dissection after acute Type A aortic dissection (TAAAD) repair has an associated but not well defined risk for aneurysmal degeneration. The purpose of this study was to investigate potential risk factors and outcomes associated with rapid aortic growth in the residually

We sought to define thromboembolic risk after surgery for mitral regurgitation (MR), particularly ischemic stroke (IS) compared with the general population.Guidelines recommend surgery in asymptomatic patients with MR, but IS risks are unknown.In 1,344 patients (age 65 +/- 12 years) consecutively operated for MR (procedures: 897 mitral valve repair [MRep] and 447 valve replacement: 231 mechanical mitral valve replacement [MVRm], 216 biological mitral valve replacement [MVRb]), thromboembolic complications, particularly IS (diagnosed by neurologists), during follow-up were assessed early (30 days), midterm (30 to 180 days), and long-term (or=180 days).Ischemic stroke occurred in 130 patients: 1.9 +/- 0.4% and 2.7 +/- 0.5% at 30 days and 180 days, respectively, and 8.1 +/- 0.8% at 5 years. We found that IS rates were lowest after MRep versus MVRb and MVRm (6.1 +/- 0.9% vs. 8 +/- 2.1%, and 16.1 +/- 2.7% at 5 years, respectively, p0.001). Comparison with population-expected IS showed high risk at30 days (risk ratio 41, 95% confidence interval 26 to 60, p0.001 but p0.10 between procedures) and moderate risk at30 days (risk ratio 1.7 overall; 1.3 for MRep; 0.98 for MVRb; 4.8 for MVRm). Beyond 180 days, IS risk declined further and was similar to the population for MRep (relative risk 1.2) and for MVRb (relative risk 0.9). Bleeding risk30 days was lowest in MRep versus MVRb and MVRm (10-year risk 7 +/- 1%, 14 +/- 4%, and 16 +/- 3%, respectively).Thromboembolic complications after MR surgery are a reason for both concern and encouragement. The risk of IS is notable early, irrespective of procedure, but in the long term it is not greater than in the population after MRep and MVRb. Preference for MRep should be emphasized, and trials aiming at preventing IS should be conducted to reduce thromboembolic and hemorrhagic risk after surgery for MR.

We sought to examine temporal trends in the utilization of coronary revascularization in a geographically defined population.Earlier reports on revascularization utilization focused on inpatient settings and did not distinguish incident from recurrent procedures. Furthermore, little is known on age- and gender-specific trends. Finally, longitudinal data on the utilization and results of coronary angiography as explanatory factors for the changing revascularization practice are lacking.Data integrating diagnostic and therapeutic coronary procedures performed in Olmsted County (Minnesota) between 1990 and 2004 were analyzed. Standardized rates were calculated applying the direct method and temporal trends compared using Poisson regression models.Revascularization utilization increased by 24% during the study (95% confidence interval [CI] 5% to 46%), but the trends diverged by procedure type, with a sustained increase (69%, 95% CI 43% to 101%) for percutaneous coronary interventions (PCI) contrasting with a stabilization, then decline (-33%, 95% CI -16% to -47%) for coronary artery bypass grafting (CABG). For PCI, although the use increased in all categories, greater increases were noted in the elderly, in women, and for recurrent procedures. No such patterns were detected for CABG. Angiography use remained stable, and the rate of 3-vessel and/or left main disease declined (-22%, 95% CI -8% to -33%).Over the 15-year period, revascularization increased in the community with a large increase in PCI partially offset by a decrease in CABG. More PCIs are performed in women and the elderly and for recurrent disease. These changes occurred within the context of a decline in multivessel disease and thus likely reflect the natural history of coronary artery disease.

OBJECTIVES We report a series of patients with severe tricuspid valve regurgitation due to a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) lead. BACKGROUND Severe tricuspid regurgitation caused by a PPM or ICD lead is an under-recognized but treatable etiology of severe right heart failure. METHODS We reviewed the records of 41 patients who underwent tricuspid valve operation for severe tricuspid regurgitation caused by previously placed PPM or ICD leads. RESULTS During surgery, severe tricuspid regurgitation was found to be caused by the PPM or ICD leads in all 41 patients. There was a perforation of the tricuspid valve leaflet by the PPM or ICD lead in 7 patients, lead entanglement in the tricuspid valve occurred in 4 patients, lead impingement of the tricuspid valve leaflets occurred in 16 patients, and lead adherence to the tricuspid valve occurred in 14 patients. The septal leaflet was most often perforated (6 of 7). In the preoperative evaluation, valve malfunction due to the PPM or ICD lead was diagnosed preoperatively in only 5 of 41 (12%) patients by transthoracic echocardiography. All patients underwent successful tricuspid valve operation (22 tricuspid valve replacement), with one perioperative death occurring. During follow-up (range, 1 to 99 months), there was one patient who died from left-sided heart failure and three patients died of other causes. The remaining patients showed improvement in signs and symptoms of heart failure. CONCLUSIONS Damage to the tricuspid valve by PPM or ICD leads may result in severe symptomatic tricuspid regurgitation and may not be overtly visualized by echocardiography. This etiology should be considered when evaluating patients with severe right heart failure after PPM or ICD implantation.

Obstructive thrombosed prosthetic heart valve (OTPHV) is a serious complication of heart valve replacement. There are no generally accepted criteria for management of these patients. Therefore, in September 2012, a literature survey of studies published after 1995 was performed to analyze the data regarding clinical outcomes of patients with OTPHV treated with thrombolytic agents and with surgery since 1996. The search yielded appropriate and relevant studies, which included 17 studies comprising 756 patients who had received thrombolytic therapy and 13 studies comprising 662 patients who had received surgery. The data on these 2 groups was analyzed in detail relating to frequency of use of the diagnostic studies, baseline patient data, and on the rate of complete success, outcomes, and complications of the therapy they had received, and the limitations of the studies. We have then developed a strategy for therapy of OTPHV.

To evaluate the prognostic importance of coronary artery disease among patients undergoing carotid endarterectomy, 177 residents of Olmsted County, Minnesota who underwent carotid endarterectomy during the period 1970 through 1988 were followed up to July 1, 1989. Patients were stratified as to the presence (n = 64) or absence (n = 93) of overt coronary artery disease or prior myocardial revascularization (n = 20) at the time of endarterectomy. At 30 days after carotid endarterectomy, there were no significant differences between patients with or without coronary artery disease in the occurrence of death, myocardial infarction or stroke. Kaplan-Meier estimate of 8-year relative survival after carotid endarterectomy (assessed as a percent of survival in age- carotid endarterectomy (assessed as a percent of survival in age- and gender-matched control subjects) was 89% in those without and 75% in those with overt coronary artery disease. Of the 59 total deaths, 29 (49%) had a cardiac cause and 4 (7%) were due to stroke (p less than 0.0001). The cumulative incidence of a cardiac event at 8 years after carotid endarterectomy was greater in those with than in those without overt coronary artery disease (61% vs. 25%, p less than 0.0001). In multivariable analysis, uncorrected coronary artery disease and diabetes were the only independent predictors of subsequent cardiac events, whereas age was the only independent predictor of death. These population-based data suggest that carotid endarterectomy can be safely undertaken in patients with stable coronary artery disease. In long-term follow-up of these patients, coronary rather than cerebral vascular disease is the most frequent cause of morbidity and mortality. Thus, these data lend strong support to the concept of early identification and management of coronary artery disease in patients undergoing carotid endarterectomy.