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Machine learning may enhance prediction of outcomes after coronary artery bypass grafting (CABG). We sought to develop and validate a dynamic machine learning model to predict CABG outcomes at clinically relevant pre- and postoperative time points.The Society of Thoracic Surgeons (STS) registry data elements from 2086 isolated CABG patients were divided into training and testing datasets and input into Extreme Gradient Boosting decision-tree machine learning algorithms. Two prediction models were developed based on data from preoperative (80 parameters) and postoperative (125 parameters) phases of care. Outcomes included operative mortality, major morbidity or mortality, high cost, and 30-day readmission. Machine learning and STS model performance were assessed using accuracy and the area under the precision-recall curve (AUC-PR).Preoperative machine learning models predicted mortality (accuracy, 98%; AUC-PR = 0.16; F1 = 0.24), major morbidity or mortality (accuracy, 75%; AUC-PR = 0.33; F1 = 0.42), high cost (accuracy, 83%; AUC-PR = 0.51; F1 = 0.52), and 30-day readmission (accuracy, 70%; AUC-PR = 0.47; F1 = 0.49) with high accuracy. Preoperative machine learning models performed similarly to the STS for prediction of mortality (STS AUC-PR = 0.11; P = .409) and outperformed STS for prediction of mortality or major morbidity (STS AUC-PR = 0.28; P.001). Addition of intraoperative parameters further improved machine learning model performance for major morbidity or mortality (AUC-PR = 0.39; P.01) and high cost (AUC-PR = 0.64; P.01), with cross-clamp and bypass times emerging as important additive predictive parameters.Machine learning can predict mortality, major morbidity, high cost, and readmission after isolated CABG. Prediction based on the phase of care allows for dynamic risk assessment through the hospital course, which may benefit quality assessment and clinical decision-making.

Investigations into readmissions after surgical repair of acute Stanford type A aortic dissection (TAAD) remain scarce. We analyzed potential risk factors for readmission after TAAD.The 2013 to 2014 US Nationwide Readmissions Database was queried for TAAD index hospitalizations and 90-day readmissions indicated by diagnostic and procedural codes. Multivariable analysis was completed to identify risk factors and the most common reasons for readmission.We identified 6975 patients (65% men; mean age, 60.0 ± 0.4 years) who underwent surgical repair for TAAD. Overall 2062 patients (29.6%) were readmitted within 90 days: 634 (30.7%) during the first 30 days and 1428 (69.3%) during days 31 through 90. Readmitted patients had a higher prevalence of chronic kidney disease at index admission (18.0% vs 11.6%, P = .002), greater overall index length of stay (17.8 ± 0.6 vs 15. 5 ± 0.4 days; P = .0003), and greater index hospitalization cost ($90,637 ± $2691 vs $80,082 ± $2091; P = .0003). Mortality during readmission was 3.6% (n = 74). Indications for readmission were most commonly cardiac (26.2%), infectious (17.8%), and pulmonary (11.7%). Multivariate analysis identified 2 independent risk factors for readmission: acute kidney injury (odds ratio, 1.49; 95% confidence interval, 1.24-1.78; P.0001) and an Elixhauser comorbidity index4 (odds ratio, 1.26; 95% confidence interval, 1.06-1.49; P = .009).After surgical repair of TAAD, approximately 30% of patients were readmitted within 90 days, two-thirds of them during the 31- to 90-day period. Targeted improvements in perioperative care and postdischarge follow-up of patients with multiple comorbidities could mitigate readmission rates. Efforts to reduce readmissions should be continued throughout the 90-day period.

Background We investigated the relationship of sex with clinical outcomes after proximal aortic (ascending and arch) operations, and whether sex-specific preoperative factors are associated with mortality. Methods Of 3745 patients who underwent elective, urgent, and emergency proximal aortic operations over a 20-year period, 1153 pairs of men and women were propensity-matched, and their early and long-term outcomes were compared. Kaplan-Meier survival analysis was used to estimate late survival. Results Women and men had similar operative mortality (9.1% vs 8.8%, P = .8), stroke (5.7% vs 5.6%, P = .9), and renal failure rates (7.0% vs 6.6%, P = .7). Thirty-day mortality was 7.5% vs 5.6% (P = .06), respectively. Results were less favorable for women than for men regarding respiratory failure (34.3% vs 29.2%, P=0.008) and intensive care unit length of stay (9.11 ± 11.9 vs 7.87 ± 12.48 days; P = .023). Long-term survival was not significantly different between women and men: 66.3% (95% confidence interval [CI] 62.8%-69.5%) vs 67.1% (95% CI 63.6%-70.4%) at 5 years, and 45.9% (95% CI 41.76%-50.0%) vs 46.2% (95% CI 41.7%-50.6%) at 10 years (P = .4). Preoperative factors including diabetes, prior stroke, prior renal insufficiency, and peripheral vascular disease were associated with operative mortality in men, whereas chronic obstructive pulmonary disease was the main risk factor in women. Conclusions No differences were seen between the sexes in life-changing adverse outcomes after ascending aortic and arch procedures, although specific preoperative variables were associated with specific adverse events. Recognizing differences in preoperative risk factors for mortality between the sexes may facilitate targeted preoperative assessment, preparation, and counseling.

BACKGROUND. The incidence and financial impact of persistent opioid use (POU) after open aortic surgery is undefined. METHODS. Insurance claim data from opioid-naïve patients who underwent aortic root replacement, ascending aortic replacement, or transverse arch replacement from 2011 to 2017 were evaluated. POU was defined as filling an opioid prescription in the perioperative period and between 90 and 180 days postoperatively. Postoperative opioid prescriptions, emergency department visits, readmissions, and health care costs were quantified. Multivariable logistic regression identified risk factors for POU, and quantile regression quantified the impact of POU on postoperative health care costs. RESULTS. Among 3240 opioid-naïve patients undergoing open aortic surgery, 169 patients (5.2%) had POU. In the univariate analysis, patients with POU were prescribed more perioperative opioids (375 vs 225 morphine milligram equivalents, P < .001), had more emergency department visits (45.6% vs 25.4%, P < .001), and had significantly higher health care payments in the 6 months postoperatively ($10,947 vs $7223, P < .001). Independent risk factors for POU in the multivariable logistic regression included preoperative nicotine use and more opioids in the first perioperative prescription (all P < .05). After risk adjustment, POU was associated with a $2439 increase in total health care costs in the 6 months postoperatively. CONCLUSIONS. POU is a challenge after open aortic operations and can have longer-term impacts on health care payments and emergency department visits in the 6 months after surgery. Strategies to reduce outpatient opioid use after aortic surgery should be encouraged when feasible.

Background: Open surgical repair of a failed valve-sparing aortic root replacement (VSARR) or stentless bioroot aortic root replacement (bio-ARR) entails significant operative risks. Whether valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is feasible in patients with a previous VSARR or stentless bio-ARR remains unclear, given lingering concerns about the ill-defined aortic annulus in these patients and the potential for coronary obstruction. We present our experience with patients who had a previous VSARR or stentless bio-ARR and underwent ViV-TAVR to repair a degenerated aortic valve with combined valvular disease, aortic insufficiency and aortic stenosis. Methods: In this retrospective data review, we identified and analyzed consecutive patients with a previous VSARR or stentless bio-ARR who underwent ViV-TAVR between December 1, 2014 and August 31, 2019. Results: ViV-TAVR was performed in twelve high-risk patients with previous VSARR or bio-ARR during the study period. Of these, seven received Medtronic Freestyle porcine stentless bioprosthetic aortic roots, three received homograft aortic roots, one underwent a Ross procedure and one underwent VSARR. ViV-TAVR restored satisfactory valve function in all patients, and technical success was 100%. No patient had more than mild regurgitation after implantation. No thirty-day mortality was seen. One patient had major bleeding after transapical access, one patient had a transient ischemic stroke, and one patient needed permanent pacemaker implantation. At a median last follow-up of 21.5 months (interquartile range, 9.0–69.0 months), all patients remained alive and had satisfactory valve function. Conclusions: In this study, ViV-TAVR was a clinically effective option for treating patients with a failed stentless bio-ARR or previous VSARR. Short-term and intermediate-term results after these procedures were favorable. These findings may have important implications for treating high-risk patients with structural aortic root deterioration and call for better transcatheter heart valves that are suitable for treating aortic insufficiency.

Background The current representation of female patients and racial and ethnic minorities in cardiovascular trials is unclear. We evaluated these groups’ inclusion in U.S. cardiovascular trials. Methods Using publicly available data from ClinicalTrials.gov , we evaluated cardiovascular trials pertaining to coronary artery bypass grafting (CABG), heart valve disease, aortic aneurysm, ventricular assist devices, and heart transplantation. This yielded 178 U.S. trials (159 completed, 19 active but not recruiting) started between September 1998 and May 2017, with 237,132 participants. To examine female patients’ and racial and ethnic minorities’ representation in these trials, we calculated participation-to-prevalence ratios (PPRs). Values of 0.8 to 1.2 reflect similar representation. Results All 178 trials reported sex distribution, whereas only 76 (42.7%) trials reported racial distribution and 52 (29.2%) trials reported ethnic (Hispanic vs non-Hispanic) distribution. Among all trials, participants were 28.3% female, 11.2% were Hispanic/Latino, 4.0% were African American, 10.4% were Asian, and 2.3% were other. The CABG PPR for female patients was 0.64, for Hispanic patients was 0.72, for African American patients was 0.28, and for Asian patients was 3.20. Between 2008-2012 and 2013-2017, the CABG PPR decreased for female patients (0.67→0.50) and African American patients (0.37→0.17) but increased for Hispanic patients (0.38→1.32) and Asian patients (3.51→4.57). Conclusions Participation in cardiovascular trials by female patients and minorities (except Asian patients) remains low. Given that inherent differences among the previously mentioned groups could affect outcomes, balance is clearly needed. The engagement of our surgical leadership, community, and industry to address these disparities is vitally important.

Objective Sarcopenia (core muscle loss) has been used as a surrogate marker of frailty. We investigated whether sarcopenia would adversely affect survival after thoracoabdominal aortic aneurysm repair. Methods We retrospectively reviewed prospectively collected data from patients aged 60 years or older who underwent thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Imaging was reviewed by 2 radiologists blinded to clinical outcomes. The total psoas index was derived from total psoas muscle cross-sectional area (cm2) at the mid-L4 level, normalized for height (m2). Patients were divided by sex-specific total psoas index values into sarcopenia (lower third) and nonsarcopenia (upper two-thirds) groups. Multivariable modeling identified operative mortality and spinal cord injury predictors. Unadjusted and adjusted survival curves were analyzed. Results Of 392 patients identified, those with sarcopenia (n = 131) were older than nonsarcopenic patients (n = 261) (70.0 years vs 68.0 years; P = .02) and more frequently presented with aortic rupture or required urgent/emergency operations. Operative mortality was comparable (sarcopenia 13.7% vs nonsarcopenia 10.0%; P = .3); sarcopenia was not associated with operative mortality in the multivariable model (odds ratio, 1.40; 95% confidence interval, 0.73-2.77; P = .3). Sarcopenic patients experienced more frequent delayed (13.0% vs 4.6%; P = .005) and persistent (10.7% vs 3.4%; P = .008) paraplegia. Sarcopenia independently predicted delayed paraplegia (odds ratio, 3.17; 95% confidence interval, 1.42-7.08; P = .005) and persistent paraplegia (odds ratio, 3.29; 95% confidence interval, 1.33-8.13; P = .01) in the multivariable model. Adjusted for preoperative/operative covariates, midterm survival was similar for sarcopenic and nonsarcopenic patients (P = .3). Conclusions Sarcopenia did not influence early mortality or midterm survival after thoracoabdominal aortic aneurysm repair but was associated with greater risk for delayed and persistent paraplegia.

Patients with postcardiotomy cardiogenic shock refractory to conventional support can be successfully supported with extracorporeal membrane oxygenation. Management considerations are discussed to aid clinicians caring for these patients.

There are limited data on the use of extracorporeal membrane oxygenation (ECMO) for pregnant and peripartum women with COVID-19 associated acute respiratory distress syndrome (ARDS). Pregnant women may exhibit more severe infections with COVID-19, requiring intensive care. We supported nine pregnant or peripartum women with COVID-19 ARDS with ECMO, all surviving and suffering no major complications from ECMO. Our case series demonstrates high-maternal survival rates with ECMO support in the management of COVID-19 associated severe ARDS, highlighting that these pregnant and postpartum patients should be supported with ECMO during this pandemic.

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To determine whether the cause of cardiomyopathy affects outcomes in patients who undergo continuous-flow left ventricular assist device support, we compared postimplant adverse events and survival between patients with ischemic and nonischemic cardiomyopathy. The inclusion criteria for the ischemic group were a history of myocardial infarction or revascularization (coronary artery bypass grafting or percutaneous coronary intervention), ≥75% stenosis of the left main or proximal left anterior descending coronary artery, or ≥75% stenosis of ≥2 epicardial vessels. From November 2003 through March 2016, 526 patients underwent device support: 256 (48.7%) in the ischemic group and 270 (51.3%) in the nonischemic group. The ischemic group was older (60.0 vs 50.0 yr), included more men than women (84.0% vs 72.6%), and had more comorbidities. More patients in the nonischemic group were able to have their devices explanted after left ventricular recovery (5.9% vs 2.0%; P=0.02). More patients in the ischemic group had gastrointestinal bleeding (31.2% vs 22.6%; P=0.03), particularly from arteriovenous malformations (20.7% vs 11.9%; P=0.006) and ulcers (16.4% vs 9.3%; P=0.01). Kaplan-Meier analysis revealed no difference in overall survival between groups (P=0.24). Older age, previous sternotomy, higher total bilirubin level, and concomitant procedures during device implantation independently predicted death (P ≤0.03), whereas cause of heart failure did not (P=0.08). Despite the similarity in overall survival between groups, ischemic cardiomyopathy was associated with more frequent gastrointestinal bleeding. This information may help guide the care of patients with ischemic cardiomyopathy who receive continuous-flow left ventricular assist device support.

The risk posed by previous isolated coronary artery bypass grafting (CABG) in patients who require proximal aortic or aortic arch surgery is unclear. We compared outcomes of ascending aortic and arch procedures in patients with and without previous CABG.Using propensity scores, we created 2 matched groups of patients who underwent proximal aortic surgery, including total arch repairs, at our institution: 126 patients who underwent isolated CABG before the index operation and 126 without previous CABG. Forty-four percent of aortic operations were emergency procedures. Eighty-six patients had a patent previous left internal mammary graft. We compared outcomes between the 2 groups and calculated Kaplan-Meier survival curves.The following outcomes were recorded for the patients with previous isolated CABG versus no CABG: operative mortality, 15.9% versus 11.1% (P = .3); 30-day mortality, 13.5% versus 7.1% (P = .1); persistent stroke, 6.3% versus 4.8% (P = .6); and renal failure necessitating hemodialysis at discharge, 7.9% versus 4.0% (P = .2). Previous CABG did not independently predict any adverse outcome, even though patients who underwent previous CABG more frequently needed intra-aortic balloon support (P .01). The P value for the overall intergroup difference in long-term survival was .06.This is one of the largest studies yet reported to examine the impact of previous isolated CABG on proximal aortic or arch surgery outcomes. Although these results may be specific to aortic centers of excellence, in this complicated patient cohort, previous isolated CABG did not independently predict any adverse outcome. These results could serve as a benchmark for assessing future endovascular therapies.

Executive Summary Cardiothoracic surgical patients are at risk of increased coronavirus disease severity. Several important factors influence the administration of the coronavirus disease vaccine in the perioperative period. This guidance statement outlines current information regarding vaccine types, summarizes recommendations regarding appropriate timing of administration, and provides information regarding side effects in the perioperative period for cardiac and thoracic surgical patients.

Background: Patients with genetic or heritable aortic conditions and thoracic aortic aneurysm syndrome often develop cardiovascular abnormalities originating at the aortic root and affecting the entire thoracoabdominal aorta. Although thoracic endovascular aortic repair (TEVAR) is usually avoided in these patients, TEVAR may be worthwhile for those at high risk for surgical complications and in certain emergency circumstances. We explored indications for TEVAR in patients with suspected or confirmed genetic or heritable aortic conditions and investigated early and mid-term outcomes. Methods: Our institutional aortic surgery database was queried for patients with suspected or confirmed Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, neurofibromatosis, or familial aortic aneurysm and dissection who underwent TEVAR between February 1, 2002 and October 31, 2020. We extracted operative details and in-hospital, follow-up, and survival data. Results: Thirty-seven patients who underwent 40 endovascular interventions met the inclusion criteria; 25 previously underwent ascending aorta or aortic root surgery, and 21 previously underwent open thoracoabdominal surgery. Postoperative complications included respiratory failure (24.3%), cardiac complications (16.2%), renal failure (13.5%), tracheostomy (8.1%), and spinal cord ischemia (paraplegia/paraparesis) (8.1%). Follow-up ranged from 1.3 to 8.5 years (median: 3.6 years), with 15 deaths overall (three early/in-hospital). Thirteen patients (35.1%) had 22 repeat interventions (open and endovascular) post-TEVAR; five had the endograft removed. Conclusions: Despite consensus that thoracic aneurysms in patients with genetic or heritable aortic conditions should be treated with conventional open surgery, the outcomes from our study suggest that TEVAR might be suitable in emergency settings or for patients in this population who are not candidates for open surgery, who are at high risk for reintervention, or who have a previously implanted Dacron graft. Nonetheless, lifelong surveillance is important for these patients after TEVAR to monitor for new dissection at distal or proximal landing zones, as repeat interventions are frequent.

Objective We determined the effect of antegrade stent delivery in the descending thoracic aorta on short- and mid-term clinical and imaging outcomes for patients who underwent repair of acute DeBakey type I aortic dissection. Methods Outcomes were evaluated for 178 patients who underwent acute type I aortic dissection between 2005 and 2016 (standard repair, n = 115 [64.6%]; antegrade stent delivery, n = 63 [35.4%]). Propensity score match and multivariable analyses were performed to assess outcomes. Results The stent and standard repair groups had similar rates of operative mortality (30-day or in-hospital) (12.7% vs 17.4%, P = .41), persistent stroke (6.3% vs 5.3%, P = .75), and persistent paraplegia/paraparesis (1.6% vs 0.9%, P = 1.0). Propensity score match analysis indicated that the operative mortality rate was higher in the standard repair group (P = .059), which the multivariable analysis confirmed. The persistent stroke rate was nonsignificantly higher in the stent group (P = .66). Persistent paraplegia/paraparesis rates were similar in both groups (P = 1.0), and the overall rates of spinal cord ischemia were nonsignificantly higher in the stent group (P = .18). During follow-up (mean duration, 4.6 ± 3.6 y), computed tomography showed that stented patients more often had remodeling of the descending thoracic aorta (P = .0002) and somewhat more often had remodeling of the thoracoabdominal aorta (P = .13). Stented patients also had fewer subsequent procedures (P = .25). The 3- and 5-year survivals were 73.3% ± 6.9% and 49.9% ± 7.6% in the matched stented group and 66.3% ± 9.4% and 41.6% ± 7.7% in the matched standard group, respectively (P = .015 for overall survival). Conclusions In the short term, antegrade stent delivery was associated with less operative mortality. In the mid-term, promising remodeling of the false lumen was seen in stented patients, as were (nonsignificantly) lower rates of subsequent procedures in the thoracoabdominal aorta. Mid-term survival was also greater in the stented patients.

Extracorporeal membrane oxygenation (ECMO) has been used for more than 50 years as salvage therapy for patients with severe cardiopulmonary failure refractory to conventional treatment. ECMO was first used in the 1960s to treat hypoxemic respiratory failure in newborns. On the basis of its success in that population, ECMO began to be used in the early 1970s to treat adult hypoxemic respiratory failure. However, outcomes for adults were, somewhat perplexingly, quite poor. By the 1980s, use of ECMO for severe hypoxemia was rare outside of the pediatric population. ECMO technology, however, continued to evolve and improve. Multiple case reports and small series describing ECMO use as rescue for adults with severe hypoxemia from various lung pathologies have appeared in the literature over the past three decades. Adult respiratory distress syndrome (ARDS) is often the final common pathway of various pathologies affecting adults and causing hypoxemic respiratory failure. It is prevalent in intensive care units throughout the world and has, since it was first described in 1967, carried a high mortality. No specific therapy for ARDS has been found, and current care is supportive, primarily by mechanical ventilation. Results from recent randomized controlled trials, however, suggest that ECMO may have a place in the treatment of these patients. This article reviews these studies and recommends adding severe ARDS to the list of established indications for ECMO in patients with hypoxemic respiratory failure.

Background Acute kidney injury (AKI) necessitating renal replacement therapy adversely affects outcomes after thoracoabdominal aortic aneurysm (TAAA) repair. The effects of earlier stages of AKI are less known. We hypothesized that earlier stages of AKI would reduce early survival after TAAA repair. Methods We analyzed prospectively collected data from 1,056 consecutive TAAA repairs from our institution (2006 to 2016). We excluded patients less than 18 years of age, those with preexisting renal disease, and three patients who died intraoperatively, resulting in 873 patients. The Kidney Disease Improving Global Outcomes criteria grouped patients into three AKI stages; stage 3 necessitated initiation of renal replacement therapy. Multivariable modeling identified operative mortality predictors. Kaplan-Meier analysis assessed 1-year survival. Results Of 873 patients, 642 (73.5%) had no AKI and 231 (26.5%) had postoperative AKI (mild/stage 1, n = 92 [10.5%]; moderate/stage 2, n = 44 [5%]; severe/stage 3, n = 95 [10.9%]). Operative death occurred in 65 patients (7.4%): 14 (2.2%) with no AKI, 5 (5.4%) with mild AKI (p = 0.07 versus no AKI), 8 (18.2%) with moderate AKI (p = 0.02 versus mild), and 38 (40%) with severe AKI (p = 0.01 versus moderate). In multivariable analysis, moderate AKI independently predicted death (relative risk ratio: 9.4, 95% confidence interval: 3.4 to 25.9). Kaplan-Meier 1-year survival was 91.1% ± 1.2% for no AKI, 84.6% ± 3.9% for mild AKI (p = 0.07 versus no AKI), 67.4% ± 7.6% for moderate AKI (p = 0.01 versus mild), and 46.6% ± 5.3% for severe AKI (p = 0.02 versus moderate; p Conclusions Moderate/stage 2 AKI reduced early survival after TAAA repair. Prevention, earlier detection, and optimal medical management of AKI may improve survival.

Socioeconomic differences can lead to differences in how patients present with surgical conditions. We attempted to determine whether socioeconomic status (SES) affects survival outcomes after thoracoabdominal aortic aneurysm (TAAA) repair.We retrospectively reviewed prospectively collected data from 981 TAAA repairs performed on domestic (noninternational) patients between 2006 and 2016. We excluded patients18 years old (n = 3), those with no available US home address (n = 114), those not within the race and ethnicity categories assessed (n = 30), and those lost to follow-up (n = 6), leaving 832 repairs for analysis. We derived patient SES by using US Census Bureau data to estimate median household income according to patient home address. Patients were grouped into 3 SES groups: high (n = 283), middle (n = 274), and low (n = 275). Multivariable logistic regression modeling was used to identify predictors of operative mortality. Kaplan-Meier curves and Cox proportional hazards regression were used to analyze the association between SES and survival.Operative mortality occurred in 9% (n = 76) of patients. Patients of low SES had greater rates of acute symptoms, dissection, and urgent or emergency TAAA repair. However, lower SES was not an independent predictor of operative death. Kaplan-Meier analysis and Cox proportional hazards modeling did not show a significant difference in mid-term survival by SES.In our TAAA series from a single, high-volume practice, SES differences did not appear to influence operative mortality rates. In addition, SES was not associated with a difference in mid-term survival. Efforts to understand and ameliorate the greater acuity of presentation in patients of low SES appear worthwhile.

Thoracoabdominal aortic aneurysm repair is technically demanding for the surgeon and physiologically demanding on the patient. As such, it requires diligent multidisciplinary perioperative care to maximize the likelihood of a successful outcome. In this article, we discuss key principles for managing patients after open thoracoabdominal aortic aneurysm repair, which we have learned over the course of performing more than 3500 of such procedures. These principles address patient handoff between the operating room and Intensive Care Unit, resuscitation, prevention and management of spinal cord deficits, and important neurological, respiratory, cardiovascular, renal, gastrointestinal, and hematological considerations. Understanding the expected postoperative course allows for earlier recognition of deviations from that course and increases the likelihood of successful rescue of patients from adverse outcomes. Achieving positive outcomes after thoracoabdominal aortic aneurysm repair requires attention to detail across the perioperative, intraoperative, and postoperative phases of care.

Coronavirus disease 2019 (COVID-19) has substantially disrupted many processes of care related to emergency cardiac conditions, while there has been no clinical guidance regarding the management of type A aortic dissection. A retrospective multicenter study involving 52 consecutive patients (mean age 52.3, 28.9% women) with type A aortic dissection during COVID-19 pandemic was conducted at tertiary aortic centers in Michigan, Wuhan and Changsha (China). Twenty-four (46.2%) were considered clinically suspicious for COVID-19 based on radiographic lung lesions (70.8%) followed by dyspnea (25.0%), cough (12.5%), and fever (12.5%). Overall, 47 (90.4%) underwent an operation and 5 (9.6%) managed nonoperatively. All suspected patients underwent a reverse-transcriptase–polymerase-chain-reaction at arrival, whereas 82.1% in the nonsuspected (P = 0.054). Among the 24 patients either nonoperatively managed or whose operation was delayed for >24 hours, only 1 (4.2%) died. A total of 3 (6.4%) operated patients had a positive reverse-transcriptase–polymerase-chain-reaction at various timings, including 1 nonsuspected patient preoperatively and 2 with very recent COVID-19 infection. The first patient died of respiratory failure despite uneventful surgical repair and maximal medical management. The postoperative course of both patients with recent COVID-19 was characterized by severe coagulopathy requiring massive transfusions and prolonged ICU stay. However, both survived to hospital discharge. In light of the possible dismal outcomes associated with dual diagnoses of type A aortic dissection/COVID-19 and the higher-than-expected number of asymptomatic carriers, all type A dissection patients should be immediately tested for COVID-19. Surgical interventions in patients recovered from recent COVID-19 may be safe.

Left ventricular assist devices (LVADs) are increasingly used as destination therapy or as a bridge to future cardiac transplant in patients with end-stage heart failure. Extracorporeal membrane oxygenation (ECMO) can be used to bridge patients in cardiogenic shock or with decompensated heart failure to durable mechanical circulatory support. We assessed outcomes in patients in critical cardiogenic shock (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] profile 1) who underwent implantation of a continuous-flow (CF)-LVAD, with or without preoperative ECMO bridging. For this retrospective study, we selected INTERMACS profile 1 patients who underwent CF-LVAD implantation at our institution between Sep 1, 2004 and Nov 30, 2018. Of 768 patients identified, 133 (17.3%) were INTERMACS profile 1; 26 (19.5%) received preoperative ECMO support, and 107 (80.5%) did not. Postimplantation outcomes were compared between the ECMO and no-ECMO groups. No significant differences were found in 30-day mortality (15.4 vs. 15.9%, P = 0.95) or survival at 1 year (53.8 vs. 60.9%, P = 0.51). Three patients who received ECMO before CF-LVAD implantation subsequently underwent cardiac transplant. In the ECMO group, the lactate level 1 day after ECMO initiation was lower in survivors than nonsurvivors (2.7 ± 2.2 vs. 7.4 ± 4.2 mmol/L, P = 0.02; area under the curve = 0.85, P = 0.01) after CF-LVAD implantation. Bridging with ECMO to CF-LVAD implantation in carefully selected INTERMACS profile 1 patients (those who are at the highest risk for critical cardiogenic shock and for whom palliation may be the only other option) produced acceptable postoperative outcomes. Field of research: Artificial lung/ECMO.

Objective Risk-scoring systems for surgical aortic valve replacement (AVR) were largely derived from sternotomy cases. We evaluated the accuracy of current risk scores in predicting outcomes after minimally invasive AVR (mini-AVR). Because transcatheter AVR (TAVR) is being considered for use in low-risk patients with aortic stenosis, accurate mini-AVR risk assessment is necessary. Methods We reviewed 1,018 consecutive isolated mini-AVR cases (2009 to 2015). After excluding patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores ≥4, we calculated each patient’s European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, TAVR Risk Score (TAVR-RS), and age, creatinine, and ejection fraction score (ACEF). We compared all 4 scores’ accuracy in predicting mini-AVR 30-day mortality by computing each score’s observed-to-expected mortality ratio (O:E). Area under the receiver operating characteristic (ROC) curves tested discrimination, and the Hosmer–Lemeshow goodness-of-fit tested calibration. Results Among 941 patients (mean age, 72 ± 12 years), 6 deaths occurred within 30 days (actual mortality rate, 0.6%). All 4 scoring systems overpredicted expected mortality after mini-AVR: ACEF (1.4%), EuroSCORE II (1.9%), STS-PROM (2.0%), and TAVR-RS (2.1%). STS-PROM best estimated risk for patients with STS-PROM scores 0 to Conclusions In low-risk patients who underwent mini-AVR, current surgical scoring systems overpredicted mortality 2-to-3-fold. Alternative dedicated scoring systems for mini-AVR are needed for more accurate outcomes assessment.

The novel coronavirus disease (COVID‐19) pandemic has created major challenges and disruptions to hospitals throughout the world, with profound implications for cardiac surgery and cardiac surgeons. In this review, we highlight the hospital and cardiac surgical experience at Baylor St. Luke's Medical Center in the Texas Medical Center in Houston, Texas as of mid‐July 2020. Our local experience has consisted of a spring surge (early March to early May), followed by a relative flattening and then a summer surge (early June to present day), similar to a sine wave. Throughout the entire pandemic, our simultaneous medical priorities have been treating the growing number of patients with COVID‐19 while continuing to provide needed care for those without COVID‐19. The current situation will be the “new normal” until a vaccine becomes available. It will be vital to stay attuned to epidemiologists, public health officials, and infection control experts, because what they see today, the intensive care units will see tomorrow. The lessons we have learned are outlined in this review but can be summarized most succinctly: preparation. We must prepare in advance, stockpile supplies and personal protective equipment, have rapid and vigorous testing protocols in place, utilize technology (eg, online meetings, videoconference “office visits”), and encourage hospital‐wide and community protective efforts (social distancing, mask wearing, hand hygiene). Hopefully, the lessons learned through this challenging experience will prepare us for the next time.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication after cardiac surgery and associated with a worse outcome. The pathogenesis of CSA-AKI is complex and multifactorial. Therapeutic options for severe CSA-AKI are limited to renal replacement therapy constituting a supportive measure. Therefore, risk identification, prevention, and early diagnosis are of utmost importance to improve patient outcomes. This review aims to provide an overview of the diagnosis, pathophysiologic mechanisms, and risk factors of CSA-AKI and delineates the strategies for AKI prevention available to improve patient outcomes after cardiac surgery.

Goal-directed therapy couples therapeutic interventions with physiologic and metabolic targets to mitigate a patient's modifiable risks for death and complications. Goal-directed therapy attempts to improve quality-of-care metrics, including length of stay, rate of readmission, and cost per case. Debate persists around specific parameters and goals, the risk profiles that may benefit, and associated therapeutic strategies. Goal-directed therapy has demonstrated reduced complication rates and lengths of stay in noncardiac surgery studies. Establishing goal-directed therapy's early promise and role in cardiac surgery-namely, producing fewer complications and deaths-will require larger studies, including those with greater focus on high-risk patients.

The COVID-19 pandemic has magnified the importance of delivering high-quality healthcare while preserving limited or depleted resources. This is particularly true in cardiac surgery, which depends on the same equipment, hospital capacity, and personnel that have been re-directed to COVID-19 care. Enhanced recovery programs promote standardized, consistent perioperative care, with an emphasis on incorporating evidence-based measures to optimize the patient experience, improve outcomes and utilize resources efficiently. Developing and implementing a program in the current COVID-19 environment is a daunting task. The Society for Enhanced Recovery After Cardiac Surgery (ERAS® Cardiac), representing an international, multi-disciplinary group of experts, provides the rationale, supportive evidence, and a proposed outline for a sustainable modified program within the constraints of the COVID-19 pandemic. It is feasible to launch in the current healthcare climate and is designed to preserve resources, reduce case backlog, and protect patient and provider safety while improving patient care and preserving institutional quality metrics. The program can also create the foundation for future growth.

Objective: The present study investigated outcomes in patients with vasoplegia after cardiac surgery treated with angiotensin II plus standard-of-care vasopressors. Vasoplegia is a common complication in cardiac surgery with cardiopulmonary bypass and is associated with significant morbidity and mortality. Approximately 250,000 cardiac surgeries with cardiopulmonary bypass are performed in the United States annually, with vasoplegia occurring in 20%to-27% of patients. Design: Post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) study. Setting: Multicenter, multinational study. Participants: Sixteen patients with vasoplegia after cardiac surgery with cardiopulmonary bypass were enrolled. Interventions: Angiotensin II plus standard-of-care vasopressors (n = 9) compared with placebo plus standard-of-care vasopressors (n = 7). Measurements and Main Results: The primary endpoint was mean arterial pressure response (mean arterial pressure ≥75 mmHg or an increase from baseline of ≥10 mmHg at hour 3 without an increase in the dose of standard-of-care vasopressors). Vasopressor sparing and safety also were assessed. Mean arterial pressure response was achieved in 8 (88.9%) patients in the angiotensin II group compared with 0 (0%) patients in the placebo group (p = 0.0021). At hour 12, the median standard-of-care vasopressor dose had decreased from baseline by 76.5% in the angiotensin II group compared with an increase of 7.8% in the placebo group (p = 0.0013). No venous or arterial thrombotic events were reported. Conclusion: Patients with vasoplegia after cardiac surgery with cardiopulmonary bypass rapidly responded to angiotensin II, permitting significant vasopressor sparing.

Multiple treatment options beyond anticoagulation exist for massive and submassive pulmonary embolism to reduce mortality. For some patients, systemic thrombolytics and catheter-directed thrombolysis are appropriate interventions. For others, surgical pulmonary embolectomy can be life-saving. Extracorporeal life support and right ventricular assist devices can provide hemodynamic support in challenging cases. We propose a management algorithm for the treatment of massive and submassive pulmonary embolism, in conjunction with a multidisciplinary pulmonary embolism response team, to guide clinicians in individualizing treatment for patients in a timely manner.

Mitral annular calcification can pose a formidable surgical challenge in the setting of mitral valve replacement for mitral stenosis. Although there are reports of transapical valve-in-valve transcatheter mitral valve replacement in the setting of degenerated bioprosthetic mitral valve replacement, there is less experience with transcatheter mitral valve replacement for mitral annular calcification. This report describes a patient who previously received a transcatheter aortic valve replacement and then subsequently underwent a minimally invasive right thoracotomy for transcatheter mitral valve replacement with a successful result. We discuss technical pearls and operative considerations based on an extensive experience with minimally invasive valve surgery from a right mini-thoracotomy.

Purpose We explored if utilization of continuous flow (CF-LVADS) has increased amongst females in the age of new-generation devices, which are smaller and more durable. We also compared outcomes between female and male CF-LVAD recipients. Methods The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) was queried to identify 20,324 CF-LVAD recipients from June 2008 to December 2017, of which 4350 (21.4%) were female and 15,974 (78.6%) were male. Survival was compared after propensity matching for age ≥ 50 yr, heart failure etiology, body surface area, INTERMACS class, co-morbidities, device strategy as destination or bridge to transplant therapy, temporary mechanical circulatory support, and device type. Results In 2008, women made up 22.5% of CF-LVAD recipients but that decreased to 20.9% in 2016 (Figure 1a). After propensity matching, baseline characteristics were comparable between 2463 females and 3925 males with the exception of mean right atrial pressure / pulmonary capillary wedge pressure which was higher in women (0.50 vs 0.45, p Conclusion Women with heart failure are far less likely to receive CF-LVADs and despite propensity matching, women are more likely to present with right heart failure at time of implantation. The higher mortality risk may be due to women presenting with more advanced heart failure at time of referral for CF-LVAD.

Thoracic endovascular aortic repair (TEVAR) is a less invasive method for treating thoracic and some thoracoabdominal aortic aneurysms, dissections of the thoracic aorta and blunt traumatic aortic injury, compared with conventional open surgery. Maximizing the likelihood of a successful outcome requires diligent multidisciplinary (surgical, critical care, nursing, pharmacy, nutrition and physical therapy) perioperative care. In this article, we discuss fundamentals for managing patients after endovascular aortic aneurysm repair. These principles focus on the transition between the operating room and the intensive care unit, prevention and management of spinal cord deficits (SCD), and vital neurological, respiratory, cardiovascular, renal, gastrointestinal and hematological concerns. The better the care team understands the expected postoperative course, the earlier that deviations can be recognized and the more likely that successful rescue can be achieved to reduce the incidence and severity of adverse outcomes. Achieving optimal results after TEVAR requires attention to detail across the preoperative, intraoperative and postoperative phases of care.

Surgery, and especially cardiac surgery, is common, costly, and entails considerable risk. Significant progress has been made in recent years to improve quality, promote patient safety, and increase value and cost-effectiveness in surgical care. Enhanced Recovery After Surgery (ERAS) initiatives are increasing in popularity, improving outcomes, and enriching patient satisfaction. First developed for abdominal surgical cases, ERAS has increasingly established itself across all surgical subspecialities, including cardiac surgery. ERAS focuses on evidence-based initiatives in the preoperative, intraoperative, and postoperative phases of care to promote patient well-being and efficient care. The deliberate, judicious incorporation of technology into surgery and the periprocedural home has tremendous, revolutionary potential in all phases of care and is consistent with ERAS principles. This technology can be harnessed by physicians and the care provider team, the healthcare system, and perhaps most importantly, by patients themselves to lead to a higher level of engagement. We will explore technology's transformational capability by concentrating on cardiac surgery because of its prevalence, costs, risks, and contribution to the healthcare system's bottom line. In addition, the role that ERAS combined with technology can play in a constructive manner will be important. We discuss the disruptive effect that the COVID-19 pandemic offers to accelerate these developments. While the human cost of the pandemic has been staggering, in the post-COVID world, the lessons learned can be vital. Finally, we seek to show that the opportunities technology provides are closely related to what both patients and the physician and provider teams want. As technology inevitably becomes more integrated into healthcare, the ability to harness technology to maximize patient outcomes and well-being while promoting more efficient healthcare delivery will be critical. © Journal of Hospital Management and Health Policy. All rights reserved.