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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).

Objectives The aim of this study was to report the 2-year results of the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial and confirm the interim Bayesian analysis. Background Transcatheter aortic valve replacement (TAVR) with a self-expanding valve was noninferior to surgery in patients with severe aortic stenosis and intermediate operative risk using Bayesian statistical methods. Novel Bayesian designs have been used to shorten the time to primary endpoint analysis in randomized clinical trials, although the predictive value of Bayesian analysis compared with frequentist approaches remains debated. Methods The SURTAVI trial randomized 1,660 patients. An interim analysis was performed 1 year after the 1,400th patient was treated to estimate the primary 2-year endpoint of all-cause mortality or disabling strokes for all patients. Results The Kaplan-Meier rate for the complete 2-year primary endpoint was 12.7% in the TAVR group and 12.6% in the surgery group (0.0% difference; 95% confidence interval: −3.4% to 3.5%), compared with 12.6% with TAVR and 14.0% with surgery (−1.4% difference; Bayesian credible interval: −5.2% to 2.3%) in the interim Bayesian analysis. A comparison of individual clinical, hemodynamic, and quality-of-life endpoints using Bayesian and frequentist methods found no significant differences. Conclusions The complete analysis of all patients with aortic stenosis at intermediate risk for surgery in the SURTAVI trial confirmed the noninferiority, with respect to the frequency of all-cause mortality or disabling stroke, of TAVR to surgery, as determined in the interim Bayesian analysis. Follow-up will extend out to 10 years.

To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.

Objective The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

Severe coronary artery calcification is a challenge for percutaneous coronary intervention (PCI), particularly in left main coronary artery disease (LM-CAD). Rotational atherectomy (RA) is a useful tool for modification of calcified plaque prior to PCI. We report our experience with RA for severely calcified LM-CAD.From January 2008 to January 2017, all patients who underwent RA-assisted LM-PCI were evaluated. The study population included both protected and unprotected LM-CAD patients. Clinical characteristics and in-hospital outcomes were collected retrospectively. In-hospital outcomes included post-PCI myocardial infarction, stroke, death, emergency coronary artery bypass graft surgery, and urgent repeat PCI. Angiographic success was defined by residual stenosis20% and presence of TIMI 3 flow.Fifty-five consecutive patients who underwent RA-assisted PCI of LM-CAD were identified (mean age, 73.0 ± 10 years; 64% male). Mean left ventricular ejection fraction was 37.5 ± 15.7%. Fifty-one patients (93%) had multivessel disease and 39 patients (71%) underwent RA-assisted LM-PCI with use of a mechanical support device. The median largest burr size used was 1.5 mm. The mean number of LM stents implanted was 0.95 ± 0.3. The mean LM stent diameter and length were 3.7 ± 0.3 mm and 15.8 ± 7.5 mm, respectively. Intravascular ultrasound was used to assess vessel size and stent apposition in 20 patients (36.0%). Angiographic success was obtained in all patients (100%).Despite technical challenges, RA of the LM coronary artery can be performed safely and is associated with a high rate of angiographic success.

Background— The risk for stroke after transcatheter aortic valve replacement (TAVR) is an important concern. Identification of predictors for stroke is likely to be a critical factor aiding patient selection and management as TAVR use becomes widespread. Methods and Results— Patients enrolled in the CoreValve US Extreme Risk and High Risk Pivotal Trials or Continued Access Study treated with the self-expanding CoreValve bioprosthesis were included in this analysis. The 1-year stroke rate after TAVR was 8.4%. Analysis of the stroke hazard rate identified an early phase (0–10 days; 4.1% of strokes) and a late phase (11–365 days; 4.3% of strokes). Baseline predictors of early stroke included National Institutes of Health stroke scale score >0, prior stroke, prior transient ischemic attack, peripheral vascular disease, absence of prior coronary artery bypass surgery, angina, low body mass index (2 ), and falls within the past 6 months. Significant procedural predictors were total time in the catheterization laboratory or operating room, delivery catheter in the body time, rapid pacing used during valvuloplasty, and repositioning of the prosthesis. Predictors of stroke between 11 and 365 days were small body surface area, severe aortic calcification, and falls within the past 6 months. There were no significant imaging predictors of early or late stroke. Conclusions— Predictors of early stroke after TAVR included clinical and procedural factors; predictors of later stroke were limited to patient but not anatomic characteristics. These findings indicate that further refinement of imaging to identify anatomic factors predisposing to embolization may help improve stroke prediction in patients undergoing TAVR. Clinical Trial Registrations— URL: http://www.clinicaltrials.gov . Unique identifiers: NCT01240902, NCT01531374.

To assess trainee physicians' ability to puncture at the femoral head and complication rates when obtaining access to the common femoral artery using fluoroscopy.The common femoral artery is the most common artery accessed during cardiac catheterization. Fluoroscopy can be used to visualize the femoral head and estimate the common femoral artery location. Puncture superior or inferior to the femoral head is associated with increased rates of retroperitoneal bleeding or thrombosis, respectively. Adequate training in groin puncture technique is essential in minimizing complications and upholding patient safety.Two consecutive samples of patients were retrospectively analyzed - one from Keck Medical Center (Keck) (n = 45), and one from Los Angeles County-University of Southern California (LAC-USC) (n = 100). An attending interventional cardiologist performed all groin punctures at Keck, and a trainee performed groin puncture at LAC-USC after detailed faculty instruction. A single reviewer retrospectively analyzed all angiograms. Puncture was recorded as occurring above, below, or at the femoral head.Percentage of punctures at the femoral head between LAC-USC vs Keck was not significantly different (93.0% vs 95.6%; P=.26). There was no significant difference in percentage of punctures below and above the femoral head between both groups, and no difference in complications.Femoral artery puncture at the femoral head is associated with improved outcomes. Our data show no significant difference between attending physicians' and trainees' ability to puncture at the level of the femoral head. Groin puncture using fluoroscopy can be taught to a high proficiency level with appropriate instruction.

Blunt injuries to the innominate artery in the civilian setting are relatively rare. The majority of patients who sustain this injury will die at the scene. Those that survive transport to the hospital present difficult challenges for trauma surgeons with mortality rates that range from 10 to 25 per cent. The proximal innominate artery is more commonly injured by blunt trauma mechanisms. On the other hand, penetrating trauma more commonly involves the distal innominate artery. A 23-year-old male presented to our trauma service after a motor vehicle collision. He was an unrestrained passenger partially ejected from the vehicle. The patient was hemodynamically stable on arrival to the emergency department. He was noted to have tenderness of the neck and chest wall. On initial evaluation the patient had no signs of neurologic injury. The chest radiograph revealed a left-sided pneumothorax and a widened mediastinum. A CT scan of the chest (Fig. 1) demonstrated a mediastinal hematoma, acute extravasation of contrast adjacent to the superior vena cava, proximal filling defect of the brachiocephalic vessels, and three left rib fractures. This prompted a formal thoracic aortogram (Fig. 2) that showed an injury consistent with a pseudoaneurysm anterior to the origin of the in-nominate artery with a short segment occlusion likely due to an intimal flap distal to the pseudoaneurysm. Fig. 1 CT scan of chest showing abrupt narrowing of the innominate artery. Fig. 2 Formal aortogram showing short segment occlusion/intimal flap cistal to pseudoanuerysm. Our patient was taken to the operative room where a median sternotomy was performed and was found to have a midinnominate artery transection. He underwent an aorto-innominate artery bypass with Dacron graft and the injured proximal innominate was oversewn. The patient tolerated the procedure well and made a good recovery and was discharged from hospital after 2 weeks on aspirin. At a subsequent follow-up visit, he was well and had returned to moderate activities. Less than 5 per cent of patients who sustain blunt trauma to the ascending aorta survive transportation to the hospital. These injuries present difficult challenges to trauma surgeons with in-hospital mortality rates that range from 10 to 25 per cent.1 The proximal innominate artery is more commonly injured by blunt trauma; however, the distal innominate artery is usually injured by penetrating trauma. Multiple mechanisms of injury have been attributed to causing innominate artery injury. Vertical deceleration, as in a fall from heights (> 15 ft), as well as posterior displacement of the sternum that occurs in horizontal displacement injuries have been described.2, 3 What is common between these mechanisms is shear and stretching forces between the immobile ascending aorta and the fairly mobile proximal innominate artery. An additional mechanism includes sudden compression of the artery between the sternum and the vertebrae, accompanied by hyperextension of the neck place. Diagnosing innominate artery injuries requires a high index suspicion. Often, the clues to this injury are a combination of the mechanism, chest pain, and radiologic findings of widened mediastinum. A sudden deceleration mechanism should also raise suspicion of these types of injuries. In the case of the innominate artery, the most frequent location of injury is at the origin from the aortic arch.4 In blunt chest trauma, the innominate artery is the most common aortic branch injured.4 The pathologic finding is an intimal tear with variable size hematoma and thrombus within the media and adventitia. A small intimal defect can eventually lead to thrombus formation and occlusion. Commonly, the patient's complaint of anterior chest wall pain is nonspecific. Chest radiographs will often reveal a widened mediastinum. In a series reported by Weiman et al., five out of five patients with blunt injury to the innominate artery had a widened mediastinum on chest radiograph. If radiologic evaluation of a patient suggests a major vascular injury, an arteriogram is indicated to delineate the injury. CT angiography or formal arch aortographies are the mainstay of diagnosis in the hemodynamically stable patient. Repair of innominate artery injuries involves basic principles of thoracic vascular injury. Median sternotomy is used and can be combined with a cervical extension for more distal vascular control, if needed. Primary repair of the vessel is the preferred choice if technically feasible. In patients with partial tears, primary repair with 4-0 polypropylene suture is often possible. In the majority of cases, innominate artery injuries are best managed by the bypass exclusion technique. This approach allows management without the use of systemic herparinization, cardiopulmonary bypass, or hypothermic circulatory arrest. Angioplasty and interposition grafting have been reported, both with and without use of cardiopulmonary bypass or intra-arterial shunting. Endovascular stent grafts were initially reported for the treatment of abdominal aortic aneurysms. Studies have shown that these stent grafts are beginning to play a larger role in traumatic aortic injuries. The advantages include minimal physiologic insult and no need for heparinization allows treatment of even the most critically injured or frail patients. Disadvantages include device failure, particularly with finding an adequate length and landing zone for proximal innominate artery injuries. Home-made devices have been used with success, but multi-institutional trials with more flexible grafts are still needed. Traumatic injury to the innominate artery are rare, however, surgeons providing care for the surviving patients should have a high index of suspicion with sudden deceleration mechanisms and chest pain. In unstable patients with presumed undiagnosed thoracic vascular injury, the appropriate incision is a left anterolateral thoracotomy. In the hemodynamically stable patient, median sternotomy with or without cervical extension is the preferred exposure. The bypass exclusion technique allows for repair without the sequelae and risks from systemic heparinization and cardiopulmonary bypass.

Background >Vitamin D deficiency is the most common nutritional deficiency in the United States. It is seldom measured or recognized, and rarely is treated, particularly in critically ill patients. The purpose of this study was to investigate the prevalence and impact of vitamin D deficiency in surgical intensive care unit patients. We hypothesized that severe vitamin D deficiency increases the length of stay, mortality rate, and cost in critically ill patients admitted to surgical intensive care units. Methods We performed a prospective observational study of vitamin D status on 258 consecutive patients admitted to the Surgical Intensive Care Unit at Grady Memorial Hospital between August 2009 and January 2010. Vitamin D levels (25 [OH]2 vitamin-D3) were measured by high-pressure liquid chromatography and tandem mass spectrometry. Vitamin D deficiency was defined as follows: severe deficiency was categorized as less than 13 ng/mL; moderate deficiency was categorized as 14 to 26 ng/mL; mild deficiency was categorized as 27 to 39 ng/mL; and normal levels were categorized as greater than 40 ng/mL. Results Of the 258 patients evaluated, 70.2% (181) were men, and 29.8% (77) were women; 57.6% (148) were African American and 32.4% (109) were Caucasian. A total of 138 (53.5%) patients had severe vitamin D deficiency, 96 (37.2%) had moderate deficiency, 18 (7.0%) had mild deficiency, and 3 (1.2%) of the patients had normal vitamin D levels. The mean length of stay in the Surgical Intensive Care Unit for the severe vitamin D–deficient group was 13.33 ± 19.5 days versus 7.29 ± 15.3 days and 5.17 ± 6.5 days for the moderate and mild vitamin D-deficient groups, respectively, which was clinically significant ( P = .002). The mean treatment cost during the patient stay in the surgical intensive care unit was $51,413.33 ± $75,123.00 for the severe vitamin D–deficient group, $28,123.65 ± $59,752.00 for the moderate group, and $20,414.11 ± $25,714.30 for the mild vitamin D–deficient group, which also was clinically significant ( P = .027). More importantly, the mortality rate for the severe vitamin D–deficient group was 17 (12.3%) versus 11 (11.5%) in the moderate group ( P = .125). Because no deaths occurred in the mildly or normal vitamin D–deficient groups, we compared the mortality rate between severe/moderate and mild/normal vitamin D groups ( P = .047). Conclusions In univariate analysis, severe and moderate vitamin D deficiency was related inversely to the length of stay in the surgical intensive care unit (r = .194; P = .001), related inversely to surgical intensive care unit treatment cost (r = .194; P = .001) and mortality (r = .125; P = .023), compared with the mild vitamin D–deficient group, after adjusting for age, sex, race, and comorbidities (myocardial infarctions, acute renal failure, and pneumonia); the length of stay, surgical intensive care unit cost, and mortality remained significantly associated with vitamin D deficiency.

The objectives of this study were: 1) to delineate the temporal course of histopathologic healing as the left atrial appendage (LAA) is obliterated by a mechanical device; and 2) to compare this process with other intravascular and intracardiac implanted technologies.Intracardiac device healing is incompletely understood. We thus studied the histopathology of device-based LAA obliteration.Nine dog hearts were examined over time after LAA device placement and results were compared with human hearts with prior LAA obliteration using the same device.At 3 days in dogs, atrial surfaces were covered by fibrin, which sealed gaps between the LA wall and the device and filled the LA appendage cavity. At 45 days, endothelial cells covered the endocardial surface with underlying smooth muscle cells that sealed the device-LA interface. Regions with prior thrombus were replaced by endocardium surrounding the device membrane. Disorganized thrombus remained in the LAA body and at the periphery near the appendage walls. Mild inflammation was observed as thrombus resorbed. By 90 days, a complete endocardial lining covered the former LAA ostium. Organizing thrombus had become connective tissue, with no residual inflammation. The human necropsy hearts had similar findings. In these 4 hearts (139, 200, 480, and 852 days after implant), the ostial fabric membrane was covered with endocardium. The appendage surface contained organizing thrombus with minimal inflammation. Organizing fibrous tissue was inside the LAA cavity, prominent near the atrial wall. The LAA interior contained organizing thrombus.This intracardiac device integration study delineated healing stages of early thrombus deposition, thrombus organization, inflammation and granulation tissue, final healing by connective tissue, and endocardialization without inflammation. These observations may yield insight into cellular healing processes in other cardiac devices.

The development of drug-eluting stents (DES) is one of the critical milestones in the advances of interventional cardiology. However, clinical stent thrombosis still poses a serious potential complication. In acute ST-segment elevation myocardial infarction (STEMI), acute total vessel occlusion has a larger thrombus burden, and the use of DES in this particular setting raises safety concerns. Published data from randomized, controlled studies, observational studies and recently published meta-analyses mostly support the safety of DES use in acute STEMI. However, these studies have limited study populations and follow-up periods, so the long-term safety of DES in the setting of STEMI is still unclear, and careful consideration should be given in clinical decision-making. In this article we reviewed the findings of randomized and nonrandomized trials on the use of drugeluting versus bare-metal stents in the setting of acute STEMI.