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Reports of early failure of the Trifecta externally wrapped, bovine pericardial aortic valve prosthesis (Abbott Laboratories, Abbott Park, IL) raise concerns about its durability. This study evaluated the hemodynamic performance and explant of Trifecta valves compared with the PERIMOUNT bovine pericardial prosthesis (Edwards Lifesciences, Irvine, CA).From October 2007 to July 2017, 2305 patients received a Trifecta bioprosthesis during aortic valve replacement at Cleveland Clinic. Trends in postoperative valve hemodynamics were assessed from 4971 transthoracic echocardiograms and valve explants by systemic follow-up. To compare outcomes, 2298 patients receiving a Trifecta valve were 1:1 propensity matched from 17,281 patients receiving a PERIMOUNT bioprosthesis.Mean age at implant was 69 years in both matched groups. Compared with PERIMOUNT valves, early transvalvular mean gradient of Trifecta valves was lower (11 vs 15 mm Hg at 1 year, P.001); however, its longitudinal rate of rise was greater (P.001), resulting in 5-year mean gradients of 17 vs 16 mm Hg, and more patients experienced severe aortic regurgitation (2.4% vs 0.81%; P.001). At 5 years, 35 Trifecta valves had been explanted vs 14 PERIMOUNT valves; freedom from explant at 1, 3, and 5 years was 98.9%, 98.0%, and 95.9%, respectively, for the Trifecta group vs 99.3%, 99.0%, and 98.7% for the PERIMOUNT group (P.001).Compared with an older-generation internally mounted bovine pericardial valve, the Trifecta externally wrapped bioprosthesis exhibits superior early hemodynamic performance, but has a rapid increase in transvalvular gradient and more aortic regurgitation, with lower freedom from explant at 5 years. These findings raise concern regarding long-term Trifecta durability despite favorable early hemodynamics.

Objectives This study was designed to compare the clinical and echocardiographic characteristics, management, and outcomes of severe atrial functional mitral regurgitation (AFMR) to primary mitral regurgitation (PMR). Background AFMR remains poorly defined clinically. Methods Consecutive patients who underwent transesophageal echocardiography at our institution between 2011 and 2018 for severe mitral regurgitation with preserved left ventricular function were screened. We excluded patients with endocarditis, any form of cardiomyopathy, or prior mitral intervention. The absence of leaflet pathology defined AFMR. Outcomes included death and heart failure hospitalizations. Results A total of 283 patients were included (AFMR = 14%, PMR = 86%). Compared to PMR, patients with AFMR had more comorbidities, including hypertension (94.9% vs. 76.2%; p = 0.015), diabetes mellitus (46.2% vs. 18.4%; p Conclusions AFMR constitutes an under-recognized high-risk group, with significant comorbidities, limited therapeutic options, and poor outcomes.

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).

Failure to rescue (FTR) is gaining popularity as a quality metric. The relationship between patient frailty and FTR after cardiovascular surgery has not been fully explored. This study aimed to utilize a national database to examine the impact of patient frailty on FTR.Of 5,199,534 patients undergoing cardiovascular surgery between 2000 and 2014, 75,851 (1.5%) were identified from the Nationwide Inpatient Sample database as frail based on the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Propensity-score matching was used to adjust for patient- and hospital-level characteristics and comorbidities when comparing frail and nonfrail patients.Frail patients were on average older (68 ± 12 years vs 65 ± 12 years; P.001) and had more comorbidities including heart failure, and chronic lung, liver, or renal disease. Among 68,472 matched pairs, frail patients had significantly higher rates of FTR (13.4% vs 11.9%; P .001). This contributed to a $39,796 increase in cost per hospitalization (P.001). Renal failure, respiratory failure, pneumonia, and sepsis were most commonly associated with FTR in frail patients. When hospitals were stratified by risk-adjusted mortality, low-mortality (1st quintile) centers had significantly lower FTR rates and costs among frail patients when compared to high-mortality (5th quintile) centers.Frailty contributes significantly to FTR after cardiovascular surgery. Frail patients can expect better outcomes with lower costs at cardiac surgical centers of excellence that can adequately manage postoperative outcomes. Preoperative assessment of frailty may better guide risk estimation and identification of patients who would benefit from appropriate prehabilitative interventions to optimize outcomes.

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

To determine mechanisms of early and late failure after mitral valve repair for degenerative disease, identify factors associated with re-repair, and evaluate durability of re-repair.From January 2008 to July 2020, 330 reoperations were performed for recurrent mitral valve dysfunction after initial valve repair for degenerative disease. Mechanisms of repair failure were determined by review of preoperative imaging and operative reports. Multivariable analysis was performed to identify factors associated with likelihood of re-repair or replacement. Durability of re-repair was assessed using longitudinal analysis of postoperative echo data.Eighty-five of 330 (26%) reoperations were performed for early repair failure within 1 year and 245/330 (74%) for late failure thereafter. Suture/annuloplasty dehiscence, systolic anterior motion, hemolysis, and ventricular remodeling were more common mechanisms of early failure and disease progression and fibrosis late failure. Forty percent (34/85) of early failures were re-repaired versus 24% (59/245) of late failures. Re-repair was more common than replacement in recent years and was associated with earlier reoperation (median 1.5 vs 3.9 years; P = .0001). No in-hospital deaths occurred after re-repair; 2 patients (0.8%) died after valve replacement. Freedom from severe mitral regurgitation after re-repair was 93% at 7 years.Mitral valve re-repair can be performed with low rates of mortality and morbidity for early and late valve dysfunction. Mechanisms of early repair failure differ from those of late failure and are generally more amenable to re-repair. In selected patients who present after failed repair, we prefer mitral re-repair to valve replacement whenever technically feasible.

OBJECTIVESRepair outcomes of tricuspid regurgitation (TR) associated with ischaemic mitral regurgitation (IMR) are inferior to functional TR in terms of TR recurrence and right ventricular (RV) reverse remodelling. Our objective is to analyse right versus left heart reverse remodelling after surgery for IMR-associated TR.METHODSFrom 2001 to 2011, 568 patients with severe IMR underwent mitral valve surgery (repair 87%, replacement 13%), and 131 had concomitant tricuspid valve repair. Median follow-up was 3.0 years; 25% of living patients were followed up for 6.3 years. Longitudinal analysis of 1527 follow-up echocardiograms was performed to assess ventricular reverse remodelling and function.RESULTSUnlike the left heart, the right heart failed to reverse remodel (failed to recover ventricular function or halt dilatation). During follow-up after surgery, the right ventricle continued to dilate while the left ventricle regressed in size. RV ejection fraction decreased (46% at 1 month and 44% at 5 years), while left ventricular ejection fraction increased (33% and 37%, respectively). RV strain showed early (−11% at 1 month) and late (−12% at 5 years) dysfunction. Patients who underwent tricuspid valve repair had worse RV function. Mitral regurgitation remained stable after surgical intervention, and TR gradually recurred (37% moderate, 20% severe at 7 years).CONCLUSIONSSurgical treatment of IMR and TR along with revascularization failed to induce reverse remodelling of the right heart. These findings warrant further investigations to identify optimal timing and approach of intervention for IMR-associated TR with respect to RV remodelling.

BACKGROUND Cardiac surgery accounts for 10-15% of blood transfusions in the US, despite benefits and calls of limiting its use. We sought to evaluate the impact of a restrictive transfusion protocol on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG). METHODS Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia, and pump fluid restriction with retrograde autologous priming and vacuum-assisted drainage, use of aminocaproic acid and cell saver, intra- and postoperative permissive anemia, and administration of iron and low-dose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009 to 2012 (group A; n = 375) and 2013 to 2016 (group B; n = 322) were compared. RESULTS CABG with grafting to three or four coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 11% and 1.2%, and postoperative transfusion 20% and 5.6% (P

BACKGROUND Mitral annular calcification (MAC) is prevalent in the aging population, with recent renewed interest regarding its associations with cardiovascular risk factors, outcomes, and influence on valvular heart disease and interventions. This meta-analysis aimed to report the relationships between MAC and cardiovascular mortality and morbidity events. METHODS Relevant studies were searched from PubMed, Cochrane, and Embase databases until November 30, 2019. Associations between MAC as a binary variable with death and cardiovascular events were pooled using random-effects models. The main outcomes of interest were all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, atrial fibrillation, and procedural outcomes. RESULTS Among 799 article abstracts and 122 full-text articles screened, 26 (16 prospective and 10 retrospective) studies totaling 35 070 subjects were analyzed. MAC was associated with higher all-cause death, hazard ratio (95% confidence interval) 1.76 (1.43-2.22), and cardiovascular mortality 1.85 (1.45-23.5). It also positively correlated with myocardial infarction 1.48 (1.22-1.79), stroke 1.51 (1.22-2.05), incidental heart failure 1.55 (1.30-1.84), atrial fibrillation 1.75 (1.43-2.15), and their composite, major adverse cardiovascular events (MACE). Finally, conversion to mitral valve replacement at time of cardiac surgery was more in patients with MAC than without MAC, with odds ratio (95% confidence interval) 2.82 (1.28-6.18). CONCLUSION Mitral annular calcification was overall associated with higher rates of death, and both individual and composite cardiovascular events. The presence of increasingly encountered MAC has significant clinical implications for cardiovascular risk assessment and valvular interventions.

Staphylococcus aureus remains the most common cause of sternal surgical site infections (SSIs). Opinions on the postoperative implications of preoperative methicillin-resistant S aureus (MRSA) colonization currently differ. This study aimed to investigate whether MRSA carriage affects postoperative outcomes and safety of operation.A total of 1,774,811 cardiac surgical patients from 2009 to 2014 were identified from the National Inpatient Sample database. Among these patients, 5798 (0.33%) were MRSA carriers. Propensity-score matching was used to determine the effect of MRSA colonization on outcomes.MRSA carriers did not differ in age or sex from noncarriers, but they more often presented for urgent surgery (P .001). Among matched pairs, there was no difference in mortality (P = .76), stroke, SSIs, pneumonia, renal failure, cardiac complications, respiratory failure, or prolonged mechanical ventilation. MRSA infection (P.001), MRSA septicemia (P = 0.03), and blood transfusion (P = .003) occurred more often among MRSA carriers. There was no increase in cost (P = .12), but the hospital length of stay was longer (P = .005). Predictors of MRSA infection among carriers included age older than 85 years, rural hospital location, and diabetes. Carriers with endocarditis and drug abuse were at highest risk for MRSA infection.MRSA carriers undergoing cardiac surgery are not at higher risk for mortality or SSIs and can expect outcomes similar to those of noncarriers. Higher rates of postoperative MRSA infection and septicemia among carriers, although still very low, support the need for selective preoperative screening and prophylaxis when possible.

Severe recurrent mitral regurgitation within 1 year of mitral valve repair is usually attributed to a technical issue with the original repair procedure. However, when artificial chordae are employed to correct mitral valve prolapse, ventricular remodeling (ie, decreased ventricular size) can lead to recurrent prolapse and valve dysfunction. To illustrate this phenomenon, we present two patients who experienced early failure after undergoing mitral valve repair with artificial chordae.

Background del Nido (DN) cardioplegia is commonly used during robotic mitral valve surgery. Poor venous drainage during surgery may result in venous backpressure and washout of this one-shot cardioplegia, limiting its cardioprotective effects. Methods One hundred eighty-seven patients undergoing isolated robotic mitral valve surgery, from January 2015 to July 2017, were retrospectively reviewed. Intraoperative central venous pressure (CVP) tracings were reviewed and venous drainage was categorized as good or poor and the relationship of the quality of venous drainage to postoperative ventricular dysfunction (operationalized as the need for inotropic support during and after weaning from cardiopulmonary bypass [CPB]) was assessed. Results Drainage was judged to be good in 107 patients and poor in 79 patients. On univariate analysis, 23 patients (41%) with good drainage required inotropic support whereas 33 patients (59%) with poor drainage required inotropic support (P = .0025). On multivariable analysis, poor venous drainage remained significantly associated with inotropic use even after adjusting for cross-clamp and CPB time. Inotrope use was associated with significantly longer intensive care unit length of stay (P = .027). Conclusion Maintenance of excellent venous drainage, as assessed by CVP monitoring, should be a high priority in isolated robotic mitral valve surgery undertaken with DN cardioplegia.

Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Patients who develop POAF are more likely to experience adverse outcomes, including increased rates of death, stroke, heart failure, and hospitalizations, and higher hospital costs. Understanding the mechanisms underlying POAF is important to improve patients' outcome and optimize health systems' efficiency. Beyond classic pathogenic hypotheses, emerging evidence suggests that postoperative pericardial effusion and localized pericardial inflammation may trigger POAF. This hypothesis is supported by data from nonhuman animal models and a growing body of evidence showing that reducing postoperative pericardial effusion might reduce POAF incidence. In this review, we summarize the classic pathophysiology theories of POAF following cardiac surgery and discuss new etiologic mechanisms with a specific focus on the role of pericardial effusion and inflammation.

The effects of stroke and delirium on postdischarge cognition and patient-centered health outcomes after surgical aortic valve replacement (SAVR) are not well characterized. Here, we assess the impact of postoperative stroke and delirium on these health outcomes in SAVR patients at 90 days.Patients (N = 383) undergoing SAVR (41% received concomitant coronary artery bypass graft) enrolled in a randomized trial of embolic protection devices underwent serial neurologic and delirium evaluations at postoperative days 1, 3, and 7 and magnetic resonance imaging at day 7. Outcomes included 90-day functional status, neurocognitive decline from presurgical baseline, and quality of life.By postoperative day 7, 25 (6.6%) patients experienced clinical stroke and 103 (28.5%) manifested delirium. During index hospitalization, time to discharge was longer in patients experiencing stroke (hazard ratio, 0.62; 95% confidence interval [CI], 0.42-0.94; P = .02) and patients experiencing delirium (hazard ratio, 0.68; 95% CI, 0.54-0.86; P = .001). At day 90, patients experiencing stroke were more likely to have a modified Rankin score2 (odds ratio [OR], 5.9; 95% CI, 1.7-20.1; P = .01), depression (OR, 5.3; 95% CI, 1.6-17.3; P = .006), a lower 12-Item Short Form Survey physical health score (adjusted mean difference -3.3 ± 1.9; P = .08), and neurocognitive decline (OR, 7.8; 95% CI, 2.3-26.4; P = .001). Delirium was associated with depression (OR, 2.2; 95% CI, 0.9-5.3; P = .08), lower 12-Item Short Form Survey physical health (adjusted mean difference -2.3 ± 1.1; P = .03), and neurocognitive decline (OR, 2.2; 95% CI, 1.2-4.0; P = .01).Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.

The objective of the study was to construct a multi-parametric mitral annular calcification (MAC) score using computed tomography (CT) features for prediction of outcomes in patients undergoing mitral valve surgery. We constructed a multi-parametric MAC score, which ranges between 2 and 12, and consists of Agatston calcium score (1 point:1000 Agatston units (AU); 2 points: 1000-3000 AU; 3 points: 3000-5000 AU; 4 points:5000 AU), quantitative MAC circumferential angle (1 point:90°; 2 points: 90-180°; 3 points: 180-270°; 4 points: 270-360°), involvement of trigones (1 point: 1 trigone; 2 points: both trigones), and 1 point each for myocardial infiltration and left ventricular outflow tract extension/involvement of aorto-mitral curtain. The association between MAC score and clinical outcomes was evaluated. The study cohort consisted of 334 patients undergoing mitral valve surgery (128 mitral valve repairs, 206 mitral valve replacements) between January 2011 and September 2019, who had both non-contrast gated CT scan and evidence of MAC. The mean age was 72 ± 11 years, with 58% of subjects being female. MAC score was a statistically significant predictor of total operation time (P0.001), cross-clamp time (P = 0.001) and in-hospital complications (P = 0.003). Additionally, MAC score was a significant predictor of time to all-cause death (P = 0.046). A novel multi-parametric score based on CT features allowed systematic assessment of MAC, and predicted clinical outcomes in patients with mitral valve dysfunction undergoing mitral valve surgery.

Background : Post-operative AF (POAF) is the most common complication following cardiac surgery, occurring in 30% to 60% of patients undergoing bypass and/or valve surgery. POAF is associated with longer intensive care unit/hospital stays, increased healthcare utilization, and increased morbidity and mortality. Injection of botulinum toxin type A into the epicardial fat pads resulted in reduction of AF in animal models, and in 2 clinical studies of cardiac surgery patients, without new safety observations. Methods : The objective of NOVA is to assess the use of AGN-151607 (botulinum toxin type A) for prevention of POAF in cardiac surgery patients. This randomized, multi-site, placebo-controlled trial will study one-time injections of AGN-151607 125 U (25 U / fat pad) and 250 U (50 U / fat pad) or placebo during cardiac surgery in ∼330 participants. Primary endpoint: % of patients with continuous AF ≥ 30 s. Secondary endpoints include several measures of AF frequency, duration, and burden. Additional endpoints include clinically important tachycardia during AF, time to AF termination, and healthcare utilization. Primary and secondary efficacy endpoints will be assessed using continuous ECG monitoring for 30 days following surgery. All patients will be followed for up to 1 year for safety. Conclusion : The NOVA Study will test the hypothesis that injections of AGN-151607 will reduce the incidence of POAF and associated resource utilization. If demonstrated to be safe and effective, the availability of a one-time therapy for the prevention of POAF would represent an important treatment option for patients undergoing cardiac surgery.

Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement.From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients.Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group.Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.

The objectives of this study were to investigate patient characteristics, valve pathology, bacteriology, and surgical techniques related to outcome of patients who underwent surgery for isolated native (NVE) or prosthetic (PVE) mitral valve endocarditis.From January 2002 to January 2020, 447 isolated mitral endocarditis operations were performed, 326 for NVE and 121 for PVE. Multivariable analysis of time-related outcomes used random forest machine learning.Staphylococcus aureus was the most common causative organism. Of 326 patients with NVE, 88 (27%) underwent standard mitral valve repair, 43 (13%) extended repair, and 195 (60%) valve replacement. Compared with NVE with standard repair, patients who underwent all other operations were older, had more comorbidities, worse cardiac function, and more invasive disease. Hospital mortality was 3.8% (n = 17); 0 (0%) after standard valve repair, 3 (7.0%) after extended repair, 8 (4.1%) after NVE replacement, and 6 (5.0%) after PVE re-replacement. Survival at 1, 5, and 10 years was 91%, 75%, and 62% after any repair and 86%, 62%, and 44% after replacement, respectively. The most important risk factor for mortality was renal failure. Risk-adjusted outcomes, including survival, were similar in all groups. Unadjusted extended repair outcomes, particularly early, were similar or worse than replacement in terms of reinfection, reintervention, regurgitation, gradient, and survival.A patient- and pathology-tailored approach to surgery for isolated mitral valve endocarditis has low mortality and excellent results. Apparent superiority of standard valve repair is related to patient characteristics and pathology. Renal failure is the most powerful risk factor. In case of extensive destruction, extended repair shows no benefit over replacement.

Background Emergency surgery, blood transfusion, and reoperation for bleeding have been associated with increased operative morbidity and mortality. The recent increased use of direct oral anticoagulants and antiplatelet medications has made the above more challenging. In addition, cardiopulmonary bypass (CPB), with its associated hemodilution, fibrinolysis, and platelet consumption, may exacerbate the pre-existing coagulopathy and increase the risk of bleeding. Aim The aim of this study was to examine available literature with regard to treating patients who are on the above medications and require emergency cardiac surgery. Results Management decisions are typically made on a case-by-case basis. Surgery is delayed when possible, and less invasive percutaneous options should be considered if feasible. Attention is paid to exercising meticulous techniques, avoiding excessive hypothermia, and treating coexisting issues such as sepsis. Ensuring a dry operative field upon entry by correcting the coagulopathy with reversal agents is offset by the concern of potentially hindering efforts to anticoagulate the patient (heparin resistance) in preparation for CPB, in addition to possibly increasing the risk of thromboembolism. Conclusion Proper knowledge of anticoagulants, their reversal agents, and the usefulness of laboratory testing are all essential. Platelet transfusion remains the mainstay for antiplatelet medications. Four-factor prothrombin complex concentrate is considered in patients on oral anticoagulants if CPB needs to be instituted quickly. Specific reversal agents such as idarucizumab and andexanet alfa can be considered if significant tissue dissection is anticipated, such as redo sternotomy, but are costly and may lead to heparin resistance and anticoagulant rebound.

Changes in left ventricular global longitudinal strain (LVGLS) have recently been regarded as an early marker of left ventricular (LV) dysfunction in patients with primary mitral regurgitation (MR). We performed a systematic review to study LVGLS as a marker for detection of post-operative outcomes

The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting.This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting.From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important:75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality.A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target-77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival.In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.

Background Wearable wrist-monitors offer an unobtrusive way to acquire heart rate data in an efficient manner. Previous work in this field has focused on studying healthy subjects during exercise but has yet to assess the efficacy of these devices in patients suffering from common cardiac arrhythmias such as atrial fibrillation. Objective The objective of this pilot study was to assess the accuracy of the Apple Watch heart rate monitor in fifty patients experiencing atrial fibrillation compared to telemetry. Results Results from this pilot clinical study demonstrated a correlation coefficient of 0.7 between all readings on the Apple Watch and telemetry. Furthermore, the Apple Watch assessed heart rate more accurately in patients who were in atrial fibrillation than in those that were not (rc = 0.86, patients in AF, vs. rc = 0.64, patients not in AF). Clinical Impact The presented data from this pilot study suggests that caution should be noted before using the Apple Watch 4 wearable wrist monitor to monitor heart rate in patients with cardiac arrhythmias such as atrial fibrillation., Apple Watch Series 4 includes a built in ECG sensor to assess heart rhythm and detects heart rate via photoplethysmography (PPG). A green light source (~540 nm) illuminates the skin and a photodetector measures the intensity of the reflected light. Heart rate is then estimated based on the pulsatile changes in reflected light induced by fluctuations in blood flow every heartbeat.

Objectives This study sought to determine whether baseline left ventricular global longitudinal strain (LV-GLS) and changes in left ventricular ejection fraction (LVEF) in a subgroup of subjects at post-operative follow-up added prognostic value in patients undergoing aortic valve (AV) surgery. Background In patients with chronic severe aortic regurgitation (AR) and preserved LVEF, sensitive markers are needed to decide timing of AV surgery. Methods This was an observational study in 865 patients (asymptomatic/mildly symptomatic, 52 ± 15 years of age, 79% men) with ≥3+ chronic AR and preserved LVEF of ≥50% who underwent AV surgery between 2003 and 2015. All patients had baseline echocardiography (and LV-GLS imaging), whereas 285 patients underwent post-operative echocardiography (including LV-GLS). Primary outcome was mortality. Results Only 478 patients (56%) patients had preoperative LV-GLS values better than −19%, despite a mean LVEF of 57 ± 4%. At a median 38 days, 632 patients underwent AV replacement, whereas 233 patients had AV repair. At a median follow-up of 6.95 (interquartile range [IQR]: 5.2 to 9.1) years, 105 patients (12%) died (2% in-hospital deaths). A higher proportion of patients with baseline LV-GLS grades worse than −19% died versus those whose LV-GLS score was better (15% vs. 10%; p Conclusions In patients with ≥3+ chronic AR and preserved LVEF undergoing AV surgery, a baseline LV-GLS value worse than −19% was associated with reduced survival. In a subgroup of patients who returned for 3- and 12-month follow-up examinations, persistently impaired LV-GLS was associated with increased mortality.

BACKGROUND AND AIM Intraoperative assessment of the repaired mitral valve (MV) by saline testing is a standard maneuver in MV repair. Despite a growing interest in application of nonresectional techniques, the utility of the saline test following repair with neochordae has not been systematically assessed. We sought to determine the accuracy of the saline test following MV repair using nonresectional techniques. MATERIALS AND METHODS We included 25 adult patients undergoing MV repair for degenerative valve disease between November 2018 and February 2019. The surgical repair was performed using nonresectional techniques with neochordae either through a sternotomy or a robotic approach. RESULTS Twenty-five patients underwent successful MV repair, all with excellent echocardiographic results. In four patients (16%), the saline test suggested discrete areas of leaflet malcoaptation and leakage, leading to additional repair maneuvers. In 16 patients (64%), the final saline test demonstrated excellent coaptation with little or no leak. In nine patients (36%), the final saline test was inconclusive (ventricle could not be filled) or poor (diffuse leak). Post-repair intraoperative echocardiography demonstrated no or trivial mitral regurgitation in all patients, and no patient required a second pump run. CONCLUSION After repair with neochordae, a satisfactory saline test indicates a good repair and discrete leaks on the saline test suggest the need for further surgical maneuvers. If the surgeon has employed standard repair techniques using neochordae but the saline test is inconclusive or poor, additional repair maneuvers are generally unnecessary, as intraoperative echocardiography will usually demonstrate a good repair.

Mitral valve (MV) repair is the procedure of choice to correct mitral regurgitation caused by degenerative MV disease, due to its well-documented superiority over MV replacement. Repair of the MV is feasible in more than 95% of such patients and restores valve function and preserve ventricular function. Surgeons choose from a wide variety of mitral repair techniques, with the ultimate procedure based upon the pathology and the particular surgeon's personal preference. As a result, there is considerable controversy concerning choice of repair techniques and prostheses (ie, annuloplasty device). This targeted review of available data concerning repair of the degenerative valve will inform surgeon decision-making in MV repair.

BACKGROUND AND AIM To compare outcomes of patients treated with inhaled epoprostenol and low tidal volume ventilation during cardiopulmonary bypass with those who did not receive this medication in the operating room at all, and those who received it as a rescue therapy at the end of the case. METHODS Retrospective chart review between 2014 and 2017, follow-up included the entire hospital stay. RESULTS Seventy-one patients were included, and mean age was 54 years. 78.9% of the patients were male. Procedures included 96% (n = 68) aortic valve replacement, 28% (n = 20) reconstruction of the intravalvular fibrosa, and 13% (n = 9) repair of an endocarditis-related intracardiac fistula. Patients who received epoprostenol (iEpo) (treatment and rescue groups), when compared with the control group had more intra-aortic balloon pump placement (23% vs 2.5%, P = .018), open chest after surgery (32% vs 7.5%, P = .012), and duration of mechanical ventilation (8.3 ± 2.7 vs. 2.4 ± 0.4 days, P = 0.01). There was no significant difference between the two groups in terms of extracorporeal circulatory support (6.5% vs 2.5%, P = .577) and hospital death (13% vs 10%, P = .72). In a subanalysis, hospital death and duration of mechanical ventilation were higher in the recue group when compared with the treatment group (P = .004 and .056, respectively). CONCLUSIONS Prophylactic application of iEpo with low tidal volume ventilation for an anticipated complex endocarditis operation may contribute to favorable outcome when compared with postoperative epoprostenol rescue.

Background: To assess the accuracy of four wearable heart rate (HR) monitors in patients with established cardiovascular disease enrolled in phase II or III cardiac rehabilitation (CR). Methods: Eighty adult patients enrolled in phase II or III CR were monitored during a CR session that included exercise on a treadmill and/or stationary cycle. Participants underwent HR monitoring with standard ECG limb leads, an electrocardiographic (ECG) chest strap monitor (Polar H7), and two randomly assigned wrist-worn HR monitors (Apple Watch, Fitbit Blaze, Garmin Forerunner 235, TomTom Spark Cardio), one on each wrist. HR was recorded at rest and at 3, 5, and 7 minutes of steady-state exercise on the treadmill and stationary cycle. Results: Across all exercise conditions, the chest strap monitor (Polar H7) had the best agreement with ECG (r c =0.99) followed by the Apple Watch (r c =0.80), Fitbit Blaze (r c =0.78), TomTom Spark (r c =0.76) and Garmin Forerunner (r c =0.52). There was variability in accuracy under different exercise conditions. On the treadmill, only the Fitbit Blaze performed well (r c =0.76), while on the stationary cycle, Apple Watch (r c =0.89) and TomTom Spark (r c =0.85) were most accurate. Conclusions: In cardiac patients, the accuracy of wearable, optically based HR monitors varies, and none of those tested was as accurate as an electrode-containing chest monitor. This observation has implications for in-home CR, as electrode-containing chest monitors should be used when accurate HR measurement is imperative.

Objectives This study investigated sex-based differences in outcomes after mitral valve (MV) surgery for severe ischemic mitral regurgitation (SIMR). Background Whether differences in outcomes exist between men and women after surgery for SIMR remains unknown. Methods Patients enrolled in a randomized trial comparing MV replacement versus MV repair for SIMR were included and followed for 2 years. Endpoints for this analysis included all-cause mortality, major adverse cardiovascular and cerebrovascular events (MACCE) (defined as the composite of death, stroke, hospitalization for heart failure, worsening New York Heart Association functional class or MV re-operation), quality of life (QOL), functional status, and percentage of change in left ventricular end-systolic volume index (LVESVI) from baseline through 2 years. Results Of 251 patients enrolled in the trial, 96 (38.2%) were women. Compared with men, women had smaller LV volumes and effective regurgitant orifice areas (EROA) but greater EROA/left ventricular (LV) end-diastolic volume ratios. At 2 years, women had higher rates of all-cause mortality (27.1% vs. 17.4%, respectively; adjusted hazard ratio [adjHR]: 1.85; 95% confidence interval [CI]: 1.05 to 3.26; p = 0.03) and of MACCE (49.0% vs. 38.1%, respectively; adjHR: 1.58; 95% CI: 1.06 to 2.37; p = 0.02). Women also reported worse QOL and functional status at 2 years. There were no significant differences in the percentage of change over 2 years in LVESVI between women and men (adjβ: −10.4; 95% CI: −23.4 to 2.6; p = 0.12). Conclusions Women with SIMR displayed different echocardiographic features and experienced higher mortality and worse QOL after MV surgery than men. There were no significant differences in the degree of reverse LV remodeling between sexes. (Comparing the Effectiveness of Repairing Versus Replacing the Heart9s Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation [Severe Ischemic Mitral Regurgitation]; NCT00807040)

Myocardial strain measured by speckle-tracking echocardiography detects subtle regional and global left ventricular dysfunction. Myocardial strain is measured in the longitudinal, circumferential, and radial dimensions; however, it is unclear which dimension of strain is the best predictor of postoperative outcomes.A secondary analysis of prospectively collected data from a clinical trial (NCT01187329).The cardiothoracic surgical operating rooms of an academic tertiary-care center.Cardiothoracic surgery patients with aortic stenosis having aortic valve replacement (AVR) with or without coronary artery bypass grafting enrolled in a clinical trial.Myocardial deformation analysis from standardized investigative transesophageal echocardiographic examinations performed after induction of anesthesia.The authors compared the ability of intraoperative global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) strain to predict adverse postoperative outcomes, including prolonged hospitalization and the need for pharmacologic hemodynamic support after cardiac surgery. The association of GLS, GCS, and GRS with prolonged hospitalization (7 days) and the need for pharmacologic hemodynamic support, with epinephrine or norepinephrine after cardiopulmonary bypass, were assessed using separate multivariable logistic regression models with adjustment for multiple comparisons. Of 100 patients, 86 had acceptable measurements for GLS analysis, 73 for GCS, and 72 for GRS. Worse GLS was associated with prolonged hospitalization [odds ratio [OR] (98.3% confidence interval [CI]) of 1.21 (1.01-1.46) per-unit worsening in strain (p = 0.01, significance criterion0.0167)] and the need for inotropic support with epinephrine [OR (99.2% CI) of 1.81 (1.10-2.97) per-unit worsening in strain (p = 0.002, significance criterion0.0083)], but not norepinephrine. GCS and GRS were not associated with adverse outcomes.GLS, but not GCS or GRS, predicts prolonged hospitalization and the requirement for inotropic support with epinephrine after AVR.

Effective drugs for atrial fibrillation (AF) are lacking, resulting in significant morbidity and mortality. This study demonstrates that network proximity analysis of differentially expressed genes from atrial tissue to drug targets can help prioritize repurposed drugs for AF. Using enrichment analysis of drug-gene signatures and functional testing in human inducible pluripotent stem cell (iPSC)-derived atrial-like cardiomyocytes, we identify metformin as a top repurposed drug candidate for AF. Using the active compactor, a new design analysis of large-scale longitudinal electronic health record (EHR) data, we determine that metformin use is significantly associated with a reduced risk of AF (odds ratio = 0.48, 95%, confidence interval [CI] 0.36-0.64, p 0.001) compared with standard treatments for diabetes. This study utilizes network medicine methodologies to identify repurposed drugs for AF treatment and identifies metformin as a candidate drug.

The emergence of mitral valve repair as the preferred treatment for severe mitral regurgitation (MR) caused by degenerative disease has been accompanied by an increasing number of valve repair failures seen by surgeons. Consequently, the feasibility of valve re-repair vs valve replacement at the time of reoperation has become a valid clinical consideration. In this report we explore the mechanisms of mitral valve repair failure as well as factors that meaningfully influence the likelihood of a successful re-repair. We provide illustrations of techniques for re-repair that we have used with reliable success, informed by the mechanism of repair failure. Lastly, we share our outcomes for mitral valve re-repair over the last 5 years and discuss our experience using the techniques illustrated in this report.

Controversies remain in the management strategy for isolated tricuspid regurgitation (TR) because of adverse prognosis and uncertainties regarding the benefits of tricuspid valve surgery. We compared the characteristics and outcomes of a large cohort of patients with isolated TR, based on downstream tricuspid valve surgery versus medical management. Consecutive patients with isolated TR graded at least moderate-to-severe by echocardiography identified between January 2004 and December 2018 (n = 9,031, age 70 ± 15 years, 60% women) were retrospectively studied. The primary end point was time to all-cause mortality during follow-up. Outcomes were compared by management strategy using unadjusted and adjusted survival and multivariable regression analyses. Tricuspid valve surgery was performed in 632 of 9,031 of the cohort (7%), including 514 valve repairs and 118 valve replacements, with in-hospital mortality in 19 patients (2.9%). Overall, there were 3,985 all-cause deaths (44%) over mean follow-up of 2.6 ± 3.3 years. Tricuspid valve surgery was independently associated with lower mortality rate during follow-up, with hazard ratios (HRs) of 0.53 (95% confidence interval [CI] 0.45 to 0.64), and the association persisted in both primary and secondary TR subgroups. Tricuspid valve surgery also had a significantly higher rate of infective endocarditis and heart failure hospitalizations rates during follow-up, at HRs of 5.55 (95% CI 4.00 to 7.71) and 1.29 (95% CI 1.16 to 1.43), respectively. In conclusion, tricuspid valve surgery is rarely performed in isolated TR, but it is independently associated with greater survival for the overall cohort and both primary and secondary etiology subgroups. Increasing the utilization of this surgery at specialized centers is encouraged to try to improve the clinical outcomes for this challenging clinical entity.

We sought to evaluate the outcomes of patients with severe mitral stenosis (MS) resulting from mitral annular calcification and assessed the prognostic impact of co-morbidities and frailty in guiding management. Among 6,915 patients with calcific MS who underwent echocardiography between January 2011 and March 2020, a total of 283 patients with severe calcific MS were retrospectively enrolled. We calculated the Charlson co-morbidity index (CCI). Frailty was scored from 0 to 3 points, with 1 point each assigned for reduced hemoglobin, reduced albumin, and inactivity. The primary end point was all-cause death. The mean age was 72 ± 11 years. The mean mitral valve (MV) area was 1.1 ± 0.4 cm2, and the mean transmitral gradient was 12 ± 4 mm Hg. Although 33% of the patients underwent MV intervention, 67% were conservatively managed. During a median follow-up of 360 days, 35% died. Patients who underwent MV intervention had an improved prognosis compared with those who were treated conservatively, even after propensity score matching. On multivariate Cox regression analysis, higher CCI (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.04 to 1.38, p = 0.011) and frailty score (HR 1.58, 95% CI 1.12 to 2.23, p = 0.01) were predictors of all-cause mortality, and MV intervention (HR 0.45, 95% CI 0.25 to 0.83, p = 0.011) and angiotensin converting enzyme inhibitor/angiotensin receptor blocker use (HR 0.39, 95% CI 0.20 to 0.79, p = 0.009) were associated with an improved prognosis. In conclusion, patients with severe calcific MS were often frail with multiple co-morbidities and were often managed conservatively. Higher CCI and worse frailty were associated with worse prognosis, regardless of the treatment strategy. MV intervention for select patients was associated with improved prognosis.

The authors report etiologies and outcomes and devise a risk model in a large contemporary cohort of patients with isolated tricuspid regurgitation (TR).Isolated TR is a challenging clinical entity with heterogeneous etiology and often poor outcomes, with a paucity of recent research regarding the epidemiology of isolated TR.Consecutive patients with isolated TR graded at least moderate to severe on echocardiography from January 2004 to December 2018 (n = 9,045, mean age 70.4 ± 15.4 years, 60.3% women) were studied. TR etiologies were individually adjudicated as secondary or primary, with subcategories. All-cause death during follow-up was the primary endpoint, with associations between etiology and outcomes analyzed and a risk model created.Primary and secondary TR etiologies were present in 470 (5.2%) and 8,575 (94.8%) patients, respectively. The main secondary etiologies were left heart disease in 4,664 (54.4%), atrial functional in 2,086 (24.3%), and pulmonary disease in 1,454 (17.0%), and the main primary etiologies were endocarditis in 222 (47.2%), degenerative or prolapse in 86 (18.3%), and prosthetic valve failure in 79 (16.8%). There were 3,987 deaths (44.0%) over a mean follow-up period of 2.6 ± 3.3 years. In unadjusted analyses, patients with secondary TR had worse survival than those with primary TR (HR: 1.56; 95% CI: 1.32-1.85), but this result was not statistically significant in multivariable analysis. The authors devised and internally validated a risk score for predicting 1-year mortality in these patients.Secondary TR constituted 95% of isolated significant TR and conferred worse survival than primary TR in unadjusted but not adjusted analyses. The present novel risk score stratifies the risk for 1-year death and may influence decision making for management in these high-risk patients.

A number of publicly available rating algorithms are used to assess hospital performance in coronary artery bypass grafting (CABG). However, concerns remain that these algorithms fail to correlate with each other and inadequately capture the case complexity of individual center practices.Composite star ratings for isolated CABG from the Society of Thoracic Surgeons public reporting database were extracted for 2018-2019. U.S. NewsWorld Report Best Hospitals was used to extract CABG ratings as well as overall cardiology and heart surgery ranking, and the Centers for MedicareMedicaid Services Hospital Compare was used to extract CABG volume and 30-day mortality. Spearman correlation coefficients were used to assess possible relationships. Expert opinion on risk adjustment and program evaluation was incorporated.Correlations between Society of Thoracic Surgeons star rating and U.S. NewsWorld Report overall ranking in cardiology and heart surgery (r = 0.15) and Centers for MedicareMedicaid Services 30-day mortality (r = -0.27) were poor. Society of Thoracic Surgeons star rating correlated weakly with U.S. NewsWorld Report CABG ratings (r = 0.33) and with Centers for MedicareMedicaid Services CABG volume (r = 0.32), whereas the latter 2 correlated moderately (r = 0.52) with each other. Of the 75 centers with accredited cardiac surgery training programs, 13 (17%) did not participate in Society of Thoracic Surgeons public reporting. Important gaps were identified in risk assessment, and potential solutions are proposed.Correlations between current CABG public reporting systems are weak. Further work is needed to refine and standardize CABG rating systems to more adequately capture the scope and complexity of an individual center's clinical practice and to better inform patients.