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To assess and compare patient-reported long-term health-related quality of life (HRQoL) after combined proximal aortic (arch ± ascending, root) and distal aortic (descending thoracic ± abdominal) replacement using open vs multimodal/endovascular (hybrid) approaches. From 2010 to 2016, 146 adults underwent single- or multi-stage aortic arch plus descending thoracic aorta replacement, 31 open and 115 hybrid. The 2 surgical approach groups had similar preoperative characteristics and extent of surgery. Cross-sectional follow-up revealed 49 deaths (7 open, 42 hybrid). Of the 97 survivors, 72 (74%) responded to the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 survey (18 open, 54 hybrid) a median 6.2 years (15th, 85th percentiles: 3.1, 7.9) after their last aortic surgery. Predictors of HRQoL scores were identified by random forest regression. Overall physical HRQoL T-score was lower than that of population norms (46 vs 50, P0.0001); mental HRQoL T-score was similar (50 vs 50, P0.9). Neither T-score was significantly different according to surgical approach (P ≥ 0.3). Greater number of postoperative complications and history of chronic obstructive pulmonary disease were the most important predictors of lower physical HRQoL, and prior myocardial infarction was the most important predictor of lower mental HRQoL. Although extensive aortic replacement had a small long-term effect on patient-reported physical HRQoL, both physical and mental HRQoL can be preserved in survivors with both surgical approaches. Surgeons should recommend the approach they believe will yield the best long-term survival, but lifelong follow-up is crucial, and patients should understand that they may require multiple operations.

Kommerell diverticulum (KD) is an uncommon congenital vascular anomaly. This study assessed outcomes of open and endovascular repair of this disorder.Between 1997 and 2016, 152 adult patients presented with KD at Cleveland Clinic (Cleveland, OH), 87 had no intervention, and 65 underwent open repair (n = 55; 19 elephant trunk [ET] procedures [9 with aortic dissection], including 7 frozen ET, and completions with 5 thoracic endovascular aortic repairs, 2 open, and 5 lost to follow-up) or endovascular procedures (n = 10). Non-ET open KD repairs consisted of resection (n = 15), interposition graft (n = 16), patch (n = 4), or aortopexy (n = 1). Maximum KD diameter was 2.1 cm for nonsurgical patients and 3.2 cm for surgical patients. Among surgical patients, 51 of 65 had dysphagia or dyspnea. A total of 608 patient-years of follow-up were available.For patients who underwent open and endovascular procedures, after multivariable adjustment, symptoms of dysphagia and hypertension predicted the likelihood of surgery (P.05, all). There was no operative mortality. Complications included nondisabling stroke (n = 5; 8%), tracheostomy (n = 3; 4.6%), vocal cord paralysis (n = 2; 3%), and reoperation for bleeding (n = 3; 4.6%). During follow-up, 3 of 10 patients treated with hybrid or endovascular procedures required reinterventions for endoleaks. One patient had residual symptoms after aortopexy. Among nonsurgical patients, 2 patients refused surgery, and 1 died of aortic rupture, with a 4.7-cm descending aorta and a 3.4-cm KD. Seven additional patients died of nonaortic comorbidities. The remaining patients were asymptomatic, with an aortic diameter smaller than 4.5 cm.Open and endovascular approaches have a high success rate and low mortality risk. Selection of the specific type of intervention should be based on patient anatomy, additional needed procedures, and comorbid conditions.

Sport for development (SFD) agencies often face issues with resource dependency, where they encounter resource deficiencies and rely upon other organizations to build capacity and attain their organizational goals and objectives. The purpose of this study was to investigate what resource networks existed among agencies within a city-wide SFD coalition and the advantages and disadvantages of their participation. The authors examined an SFD coalition involving 27 agencies and their five resource networks: information, finance, human resources, infrastructure, and strategic planning. Results indicate the SFD agencies developed relationships across the five networks. A subgroup of well-connected agencies shared numerous relationships spanning multiple networks, and they assumed central positions with greater access to resources and more capacity in these networks. Coalition advantages, such as better service delivery to clients, outweighed disadvantages, such as limited time. The findings indicated the potential for SFD agencies to cultivate relationships, gain access to resources, and build capacity within these interorganizational networks.

The purpose of this study was to examine the influence of shared leadership and organizational capacity on organizational performance and innovative work behavior (IWB) in sport for development and peace. An electronic survey was distributed to 1,120 sport for development and peace practitioners. A total of 215 completed surveys were recorded for a response rate of 19.2%. Structural equation modeling revealed significant relationships between shared leadership and both organizational performance and IWB. In addition, shared leadership fully mediated the relationship between capacity and IWB, and partially mediated the relationship between capacity and organizational performance. Altogether, the results indicate that shared leadership and capacity combined to explain a significant proportion of variance in performance and IWB. The results provide empirical support for the significant role of shared leadership in sport for development and peace. In addition, the significant direct and indirect effects in the tested model highlight the value of examining both capacity and shared leadership.

• The concept of shared leadership and its applicability in SDP is examined.• A collective view of leadership is valuable for the distinct nature of SDP.• Nine propositions are presented regarding ...

The purpose of this study was to examine how innovative SDP organizations’ interactions with external stakeholders influence the social innovation process. Innovation represents the implementation of new or improved ways to promote social change. The authors conducted semi-structured interviews and focus groups with 48 SDP leaders representing organizations located across six continents. Innovative SDP agencies engaged in numerous non-financial relationships with a strong emphasis on collective learning, a shared willingness to spread the risk of innovation across organizational boundaries, and a reciprocal process for co-creating new and improved solutions for how sport can be used better to promote positive social change. Social innovation in the context of SDP emerged across different levels (intra-, inter-, and extra-group) from a collective and interactive process between SDP organizations and external stakeholders. Their innovation activities included identifying opportunities and generating ideas for implementing new practices and scaling creative solutions. This study extends the existing SDP literature and underscores the need to adopt a more specific external perspective when examining the process of innovation in sport organizations.

Charitable nonprofits strive to meet their organization’s goals, address external demands, and secure resources to pursue their missions. Management scholars have recommended that nonprofits promote innovation and innovative practices to maximize profits and gain a competitive advantage. However, the voices of nonprofit practitioners who implement this strategy have not been heard. We used data from interviews and focus groups with 47 practitioners representing development and peace-building nonprofits across six continents to probe what innovation means to them. Five themes emerged: (a) experimentation and social transformation, (b) financial sustainability, (c) collective solutions, (d) new means for achieving missions, and (e) adaptations to local contexts. These findings reveal discrepancies in the meaning of innovation between theory and practice. The findings from this study suggests innovation and innovative practices can have different meanings in different sectors. Perspectives on nonprofit innovation are multifaceted, yet the overarching emphasis is finding transformative ways to attain organizational goal(s) for social change.

Sport for development and peace (SDP) agencies increasingly deal with complex institutional demands. In this article, the authors present an in-depth case study of how a nascent SDP organization created from within a local community in Kenya responded to institutional complexity through a series of pivotal moments that shaped the nature of the SDP agency. Throughout the formative stage in its life course, organizational leaders faced increased institutional complexity as they grappled with a series of incompatible prescriptions and demands from multiple institutional logics. The case organization—Highway of Hope—responded to this complexity through a process of organizational hybridity. Five pivotal decision points were identified and analyzed to explore how they shaped the organization over its early stages of existence. Our findings provide guidance for advancing our understanding of hybridity processes in SDP, both theoretically and practically.

The need for new and evidence-based solutions for mobilizing stakeholders and resources in sport for development and peace (SDP) is increasingly emphasized in a number of recent policy documents including the Kazan Action Plan and a set of publications by the Commonwealth Secretariat. This paper provides a response to these calls for the development of mechanisms and toolkits to support multistakeholder collaboration. We draw on our combined experiences in SDP research, practice, and funding to identify how multistakeholder initiatives in SDP can be better leveraged. Specifically, we discuss how Brown’s (2015) five elements of bridge-building for social transformation, namely, compelling and locally relevant goals; cross-boundary leadership systems; generative theories of change; systems enabling and protecting innovation; and investment in institutionalizing change, apply in the SDP domain. The practical framework we have outlined provides a common ground and starting point to build upon for generating improved synergies among a multitude of stakeholders.

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 Unlike coronary artery bypass and aortic and mitral valve procedures, there is no predictive risk model for aortic root replacement procedures. As a first step toward development of a risk model, this study analyzed The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to determine factors predictive of mortality and morbidity in patients undergoing elective aortic root replacement (ARR). Methods The STS database was queried (from July 2011 to June 2016) for elective ARR with the following exclusion criteria: urgent or salvage cases, endocarditis, redo cardiac surgery, circulatory arrest, and aortic arch surgery. Adjusted multivariate logistic regression models for outcomes of mortality and composite STS morbidity were performed using covariates of the STS aortic valve risk set (expressed as odds ratios [ORs]). Results Of 24,244 patients undergoing ARR, 8,807 (77.6% male) met inclusion criteria in 808 centers; 33.7% (n = 2,965) had a bicuspid aortic valve, and 3.7% (n = 327) had Marfan syndrome. The median age was 58.0 years (interquartile range, 49 to 67 years). Median intensive care unit and hospital stays were 46 hours and 6 days, respectively. Significant predictors for mortality included: atrial fibrillation (OR, 2.06), body surface area (OR, 0.14), chronic obstructive pulmonary disease (OR, 1.2), New York Heart Association class IV (OR, 2.53), diabetes (OR, 2.48), coronary artery bypass grafting (OR, 2.77), mitral valve surgery (OR, ≥2.18), and Bentall operation (OR, 2.08). Regression analysis for risk factors for STS morbidity yielded 14 significant factors. A glomerular filtration rate increase of 20 units was predictive of improved mortality (OR, 0.85) and morbidity (OR, 0.91). Conclusions Elective ARR is performed with excellent postoperative outcomes. Analysis of the STS database reveals several significant risk factors that are independently associated with increased mortality and morbidity. The investigators anticipate that future studies inclusive of the nonelective ARR cases in the database will facilitate development of a risk model for root replacement procedures.

Objective: We sought to characterize microbiomes of thoracic aortas from patients with non-infectious aortitis due to giant cell arteritis (GCA) and clinically isolated aortitis (CIA) and to compare them to non-inflammatory aorta aneurysm controls. We also compared microbiomes from concurrently processed and separately reported temporal arteries (TA) and aortas. Methods: From 220 prospectively enrolled patients undergoing surgery for thoracic aorta aneurysm, 49 were selected. Inflammatory and non-inflammatory cases were selected based on ability to match for age (+/-10 years), gender, and race. Biopsies were collected under aseptic conditions and snap-frozen. Taxonomic classification of bacterial sequences was performed to the genus level and relative abundances were calculated. Microbiome differential abundances were analyzed by principal coordinates analysis. Results : Forty-nine patients with thoracic aortic aneurysms (12 CIA, 14 GCA, 23 non-inflammatory aneurysms) were enrolled. Alpha ( P = 0.018) and beta ( P = 0.024) diversity differed between specimens from aortitis cases and controls. There were no significant differences between CIA and GCA ( P > 0.7). The largest differential abundances between non-infectious aortitis and non-inflammatory control samples included Enterobacteriaceae , Phascolarctobacterium , Acinetobactor , Klebsiella , and Prevotella. Functional metagenomic predictions with PICRUSt revealed enrichment of oxidative phosphorylation and porphyrin metabolism pathways and downregulation of transcription factor pathways in aortitis compared to controls. Microbiomes of aortic samples differed significantly from temporal artery samples from a companion study, in both control and GCA groups ( P = 0.0002). Conclusion: Thoracic aorta aneurysms, far from being sterile, contain unique microbiomes that differ from those found in temporal arteries. The aorta microbiomes are most similar between aneurysms that were associated with inflammation, GCA, and CIA, but differed from those associated with non-inflammatory etiologies. These findings are promising in that they indicate that microbes may play a role in the pathogenesis of aortitis-associated aneurysms or non-inflammatory aneurysms by promoting or protecting against inflammation. However, we cannot rule out that these changes are related to alterations in tissue substrate that favor secondary changes in microbial communities.

Background: In patients with severe aortic stenosis (AS) at intermediate surgical risk, treatment with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) results in similar rates of death or stroke at 2 years. Whether TAVR is cost-effective compared with SAVR for intermediate-risk patients remains uncertain. Methods: Between 2011 and 2014, 3110 intermediate-risk AS patients were treated with TAVR or SAVR in the PARTNER 2 trial (Placement of Aortic Transcatheter Valves 2). A total of 2032 patients were randomized to receive TAVR using the SAPIEN XT valve (XT-TAVR) or SAVR in the PARTNER 2A trial, whereas the PARTNER S3i registry included an additional 1078 patients treated with TAVR using the SAPIEN 3 valve (S3-TAVR), which offers a lower delivery profile and sealing skirt designed to reduce paravalvular regurgitation compared with XT-TAVR. Procedural costs were estimated using measured resource utilization. Other in-trial costs were assessed by linkage of trial data with Medicare claims (n=2333) or by linear regression models for unlinked patients (n=682). Health utilities were estimated using the EQ-5D at baseline and 1, 12, and 24 months. Using a Markov model informed by in-trial costs, utilities, and survival data, lifetime cost-effectiveness from the perspective of the US healthcare system was estimated in terms of cost per quality-adjusted life-year gained. Results: Although procedural costs were ≈$20 000 higher with TAVR than SAVR, total cost differences for the index hospitalization were only $2888 higher with XT-TAVR ( P =0.014) and were $4155 lower with S3-TAVR ( P P P Conclusions: Among intermediate-risk AS patients, TAVR is projected to be economically dominant from the perspective of the US healthcare system by providing both greater quality-adjusted life expectancy and lower long-term costs than SAVR. If long-term data demonstrate comparable late mortality with TAVR and SAVR, these findings suggest that TAVR might be the preferred treatment strategy for intermediate-risk AS patients based on both clinical and economic considerations. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01314313.

Surveillance metrics in pediatric and young adult Marfan syndrome (pMFS) are challenging. We evaluated the utility of aortic root cross-sectional area/height index (CSA/Ht) on echocardiogram among pMFS patients as a risk stratification and surgical triage metric.Genotype or phenotype positive pMFS patients aged 25 years or younger seen at our center from 2001 to 2020 were identified. Time-related transition to surgery was modeled using parametric methods. Predictive utility of CSA/Ht compared with aortic root diameter (ARd) and root Z score (ARz) were modeled using nonlinear multivariable parametric and nonparametric longitudinal regression models.Seventy-nine patients (43% female) presented at median age of 5.8 years (15th-85th percentile, 0.75-17 years) with median follow-up of 4.4 years (range, 0-18.5 years). Baseline echocardiography data were: CSA/Ht, 3.9 ± 1.4 cmCSA/Ht tracked ARd well over time. CSA/Ht between 5 and 7 cm

OBJECTIVES This study sought to examine the association of hospital procedural volume with the incidence and outcomes of surgical bailout (SB) in patients who undergo transcatheter aortic valve replacement (TAVR). BACKGROUND SB is required for serious complications during or after TAVR. It remains unclear whether hospital experiences affect the incidence and outcomes of SB. METHODS We retrospectively identified patients who underwent endovascular TAVR using the Nationwide Readmissions Database 2012-2017. We examined the association of annual hospital procedural volume (annual number of endovascular TAVR cases in each hospital in each year) with the incidence and in-hospital mortality of SB using multivariable logistic regressions and restricted cubic splines. RESULTS Among 82,764 eligible patients, the incidence of SB was 0.95% (n = 789) and decreased from 2012 to 2017 (from 2.66% to 0.49%; Ptrend

OBJECTIVES This study aimed to evaluate the incidence, treatment, and outcomes of acute myocardial infarction (AMI) following transcatheter or surgical aortic valve replacement (TAVR or SAVR). BACKGROUND Coronary artery disease is common in patients who undergo aortic valve replacement. However, little is known about differences in clinical features of post-TAVR or post-SAVR AMI. METHODS We retrospectively identified post-TAVR or post-SAVR (including isolated and complex SAVR) patients admitted with AMI using the Nationwide Readmissions Database 2012-2017. Incidence, invasive strategy (coronary angiography or revascularization), and in-hospital outcomes were compared between post-TAVR and post-SAVR AMIs. RESULTS The incidence of 180-day AMI was higher post-TAVR than post-SAVR (1.59% vs. 0.72%; p

The Swedish Armed Forces configuration of the Weather Research and Forecasting Model (WRF) has problems in forecasting low clouds in stably stratified conditions when the ground is covered by snow. Reforecasts for January and February 2018, together with observations from Sodankylä in northern Finland, are analyzed to find the cause. The investigation is done iteratively between the Single Column Model (SCM), applied at Sodankylä, and the full 3D version. Our experiments show that the forecast error arises due to inadequate initialization of Stratocumulus (Sc) clouds in WRF using the ECMWF global model, Integrated Forecast System (IFS). By including bulk liquid water and bulk ice water content, from IFS in the initial profile, the downwelling long wave radiation increases and prevents the near surface temperature from dropping abnormally. This, in turn, prevents artificial clouds from forming at the first model level. When no clouds are present in the IFS initial profile, the Sc clouds can be initialized using information from the observed vertical profiles. Generally, initialization of Sc clouds in WRF improves the forecast substantially.

Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is an ongoing viral pandemic marked by increased risk of thrombotic events. However, the role of platelets in the elevated observed thrombotic risk in COVID-19 and utility of antiplatelet agents in attenuating thrombosis is unknown. We aimed to determine if the antiplatelet effect of aspirin may mitigate risk of myocardial infarction, cerebrovascular accident, and venous thromboembolism in COVID-19. We evaluated 22,072 symptomatic patients tested for COVID-19. Propensity-matched analyses were performed to determine if treatment with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) affected thrombotic outcomes in COVID-19. Neither aspirin nor NSAIDs affected mortality in COVID-19. Thus, aspirin does not appear to prevent thrombosis and death in COVID-19. The mechanisms of thrombosis in COVID-19, therefore, appear distinct and the role of platelets as direct mediators of SARS-CoV-2-mediated thrombosis warrants further investigation.

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.

Outpatient follow-up after hospital discharge improves continuity of care and reduces readmissions, but rates of follow-up remain low. It is not known whether electronic medical record (EMR)-based tools improve follow-up. The aim of this study was to determine if an EMR-based order to secure cardiology follow-up appointments at hospital discharge would improve follow-up rates and hospital readmission rates. A pre-post interventional study was conducted and evaluated 39,209 cardiovascular medicine discharges within an academic center between 2012 and 2017. Follow-up rates and readmission rates were compared during 2 years prior to EMR-order implementation (pre-order era 2012–2013, n = 12,852) and 4 years after implementation (EMR-order era 2014–2017, n = 26,357). The primary endpoint was 90-day cardiovascular follow-up rates within our health system. In the overall cohort, the mean age of patients was 69.3 years [SD 14.7] and 60.7% (n = 23,827) were male. In the pre-order era, 90-day follow-up was 56.7 ± 0.4% (7286 of 12,852) and increased to 67.9 ± 0.3% (17,888 of 26,357, P P P = 0.016) in the EMR-order era. An EMR-based appointment order for follow-up appointment scheduling was associated with increased cardiovascular medicine follow-up, but was not associated with an observed reduction in 30-day readmission rates.

The relationship between institutional volume and operative mortality after surgical aortic valve replacement (SAVR) remains unclear.From January 2013 to June 2018, 234 556 patients underwent isolated SAVR (n = 144 177) or SAVR with coronary artery bypass grafting (CABG) (n = 90 379) within the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The association between annualized SAVR volume (group 1 [1-25 SAVRs], group 2 [26-50 SAVRs], group 3 [51-100 SAVRs], and group 4 [100 SAVRs]) and operative mortality and composite major morbidity or mortality was assessed. Random effects models were used to evaluate whether historical (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes.The annualized median number of SAVRs per site was 35 (interquartile range, 22-59; isolated aortic valve replacement [AVR], 20; AVR with CABG, 13). Among isolated SAVR cases, the mean operative mortality and composite morbidity or mortality were 1.5% and 9.7%, respectively, at the highest-volume sites (group 4), with significantly higher rates among progressively lower-volume groups (P trend.001). After adjustment, lower-volume centers had increased odds of operative mortality (group 1 vs group 4 [reference]: adjusted odds ratio [AOR] for SAVR, 2.24 [95% CI, 1.91-2.64]; AOR for SAVR with CABG, 1.96 [95% CI, 1.67-2.30]) and major morbidity or mortality (AOR for SAVR, 1.53 [95% CI, 1.39-1.69]; AOR for SAVR with CABG, 1.46 [95% CI, 1.32-1.61]) compared with the highest-volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category, and prior outcomes explained a greater proportion of hospital operative outcomes than did prior volume.Operative outcomes after SAVR with or without CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive of future outcomes than is prior volume. Given the excellent outcomes observed at many lower-volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

In order to develop a new type of improved wound dressing, we combined the wound healing properties of nanotitania with the advantageous dressing properties of nanocellulose to create three different hybrid materials. The hemocompatibility of the synthesized hybrid materials was evaluated in an in vitro human whole blood model. To our knowledge, this is the first study of the molecular interaction between hybrid nanotitania and blood proteins. Two of the hybrid materials prepared with 3 nm colloidal titania and 10 nm hydrothermally synthesized titania induced strong coagulation and platelet activation but negligible complement activation. Hence, they have great potential as a new dressing for promoting wound healing. Unlike the other two, the third hybrid material using molecular ammonium oxo-lactato titanate as a titania source inhibited platelet consumption, TAT generation, and complement activation, apparently via lowered pH at the surface interface. It is therefore suitable for applications where a passivating surface is desired, such as drug delivery systems and extracorporeal circuits. This opens the possibility for a tailored blood response through the surface functionalization of titania.

Transcatheter aortic valve replacement (TAVR) is now frequently performed for severe aortic stenosis. Data regarding cardiac operations after TAVR are limited, however. Therefore, we investigated patient characteristics, operative timing and indications, and outcomes of these operations in a single-center experience.From January 2012 to July 2020, 59 patients (median age, 70 years) underwent cardiac operations after TAVR, 38 (64%) of which were performed in other centers. The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was calculated at the time of prior TAVRs and at applicable index cardiac operations.From 2012 to 2018, fewer than 10 operations were performed after TAVR, but 18 were performed in 2019. The interval between prior TAVR and cardiac surgery decreased exponentially from 7 years to less than 1 year over the experience. In applicable cases (19 of 59 operations [32%]), the median STS-PROM was 5.5% (15th-85th percentiles, 3.1%-25%), and 40 (68%) were complex operations with no calculable STS-PROM. The TAVR valve was explanted in 46 (78%); 5 were isolated surgical aortic valve replacements. TAVR valve stenosis/regurgitation (34 [58%]) was the leading indication, followed by paravalvular leak in 14 (24%) and endocarditis in 10 (17%). When the TAVR valve was not explanted, mitral regurgitation was the leading indication for operation. Operative death occurred in 5 (8.5%), postoperative stroke in 2 (3.4%), and postoperative dialysis in 6 (10%).Cardiac operations after TAVR are increasing, and the interval between TAVR and operation is decreasing. Most cardiac operations are complex, high-risk reoperations, and isolated aortic valve replacement is rare. These findings should be considered when TAVR is selected for low- to intermediate-risk patients, particularly with multiple cardiac pathologies not addressed by TAVR.

Emergency surgery, blood transfusion, and reoperation for bleeding have been associated with increased morbidity and mortality. Every effort is made to optimize patients preoperatively including cessation of oral anticoagulants in an attempt to normalize the coagulation profile. The recent explosive use of direct oral anticoagulants (DOACs) and antiplatelet medications has made the above more difficult. Cardiopulmonary bypass (CPB), with its associated fibrinolysis and platelet consumption, may exacerbate a pre-existing coagulopathy. In addition, the underlying surgical pathology, such as endocarditis accompanied by sepsis and disseminated intravascular coagulopathy (DIC) or aortic dissection requiring hypothermia and circulatory arrest, can aggravate an already challenged hematological profile. Ensuring a dry operative field upon entry by correcting the coagulopathy is offset by the concern of potentially hindering efforts to anticoagulate the patient in preparation for CPB, in addition to possibly creating a hypercoagulable state that could increase the risk of thromboembolic events. Management is challenging and 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. If surgery is unavoidable, attention is paid to exercising meticulous techniques, avoiding excessive hypothermia, treating coexisting issues such as sepsis and correcting the coagulopathy with antidotes, reversal agents and blood products, with the understanding that a normal coagulation profile does not necessarily translate into hemostasis or the absence of thrombosis. Proper knowledge of the mechanism of action of the oral anticoagulants, available antidotes and their time to onset are essential in properly treating this difficult patient population.

Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated.

Although coronary artery bypass grafting using bilateral internal thoracic arteries (ITA) maximizes long-term survival, knowledge of the effect of different right ITA (RITA) inflow configurations on graft patency is limited. We have compared RITA occlusion among these configurations and identified its risk factors while adjusting for outflow coronary target location.From January 1972 to January 2016, of 7092 patients undergoing bilateral ITA grafting at a single center, 1331 received one ITA to the left anterior descending coronary artery and had one or more evaluable postoperative coronary angiograms: 835 (63%) in situ, 496 free RITA grafts (311 [63%] originating from aorta; 98 [20%] left ITA [LITA], 76 [15%] saphenous vein graft, 11 [2%] radial graft). RITA occlusion reported on 1983 angiograms performed a median of 5.8 years later was estimated using nonlinear mixed-effects longitudinal modeling.RITA patency was 90% at 1 year, 87% at 5 years, and 86% at 10 and 15 years. At 15 years, in situ RITA patency was 91% and free RITA patency from aorta was 91%, LITA 89%, and saphenous vein graft 77%. After adjusting for coronary target location and degree of stenosis, occlusion was similar in free RITAs from aorta (P = .15), LITA (P = .4), saphenous vein grafts (P = .13), and in situ RITAs. However, RITAs grafted to the left anterior descending coronary artery had fewer occlusions (P.001), with patency similar to LITAs.Among patients with bilateral ITA grafting requiring interval coronary angiography, long-term RITA patency was high and independent of its inflow configuration. Therefore, priority should be a RITA configuration optimizing its reach to important coronary targets, including the left anterior descending coronary artery.

Background Reoperative cardiac surgery in patients with patent bilateral internal thoracic arteries (ITA) grafts is technically challenging. Methods From 2008–2017, of 7,640 patients undergoing reoperative cardiac surgery, 116 (1.5%) had patent bilateral ITA grafts, including 28 with a right ITA crossing the midline. Mean age was 70±9.6 years, and 111 patients (96%) were male. Reoperations included isolated coronary artery bypass grafting (CABG; n=11), isolated valve (n=55), valve+CABG (n=26), and other procedures (n=24). Clinical details, intraoperative management, and perioperative outcomes were analyzed. Results Aortic cannulation was central in 64 patients (56%) and via femoral or axillary artery in 50 (44%). Four patients (3.4%) had planned transection and reattachment of ITAs crossing the midline, and 4 (3.4%) had ITA injuries, all right ITAs, 3 crossing the midline; 3 were repaired with an interposition vein graft, and 1 was managed by translocating the right ITA as a Y-graft off another graft. Patent ITAs were managed by atraumatic occlusion during aortic clamping in 90 patients (78%) and by systemic cooling without ITA occlusion in 19. There were 6 operative deaths, all due to low cardiac output syndrome (5.2%), 4 strokes (3.4%), and 5 cases of new postoperative dialysis (4.3%). Conclusions Risk of injury to bilateral ITA grafts during reoperation is high, and right ITAs crossing the midline present a particular risk of injury and should inform planning for primary CABG. Risk of low cardiac output syndrome underscores the challenge of ensuring adequate myocardial protection.

BACKGROUND Monitored anesthesia care (MAC) has become more widely used during transcatheter aortic valve replacement (TAVR) to avoid the complications of general anesthesia (GA). METHODS We included consecutive patients who underwent transfemoral-TAVR at our institution between January 2012 and April 2017. We compared outcomes with GA versus MAC. RESULTS Of 998 patients, MAC was used in 43.9%. MAC was associated with shorter procedural time (96.9 ± 30.9 vs. 135 ± 64.6 mins; p

Background: The conventional method of implanting balloon-expandable SAPIEN-3 (S3) valve results in a final 70:30 or 80:20 ratio of the valve in the aorta:left ventricular outflow tract with published rates of permanent pacemaker around 10%. We sought to evaluate whether higher implantation of S3 reduces conduction abnormalities including the need for permanent pacemaker. Methods: We included consecutive patients who underwent transfemoral transcatheter aortic valve replacement using S3 between April 2015 and December 2018 and compared outcomes with typical valve deployment strategy to our more contemporary high deployment technique (HDT). We excluded patients with nontransfemoral access or valve-in-valve. Results: Among 1028 patients, HDT was performed in 406 patients (39.5%). Mean implantation depth under the noncoronary cusp was significantly smaller with HDT compared with conventional technique (1.5±1.6 versus 3.2±1.9 mm; P P =0.216). Thirty-day permanent pacemaker rates were lower with HDT (5.5% versus 13.1%; P P P P =0.804), or moderate-to-severe aortic regurgitation (1% versus 2.7%; P =0.081) at 1 year. HDT was associated with slightly higher 1-year mean gradients (13.1±6.2 versus 11.8±4.9 mm Hg; P =0.042) and peak gradients (25±11.9 versus 22.5±9 mm Hg; P =0.026). However, Doppler velocity index was similar (0.47±0.15 versus 0.48±0.13; P =0.772). Conclusions: Our novel technique for balloon-expandable S3 valve positioning consistently achieves higher implantation resulting in substantial reduction in conduction abnormalities and permanent pacemaker requirement after transcatheter aortic valve replacement without compromising procedural safety or valve hemodynamics. Operators should consider this as an important technique to improve patient outcomes.

The management of subacute and chronic aortic dissection should be treated according to non-dissected aortic disease, with the Class I to IV type of tear influencing management based on extent of dissection. It is important to consider extent of dilation of the aorta, brain protection, and comorbidities. Definitive operations for dilated aortas with subacute or chronic dissection may include aortic valve reimplantation and root replacement, ascending aorta tube graft, or tricuspid valve repair with ascending arch or separate tube graft replacement. An elephant trunk procedure may need to be performed for more extensive dissections.

Imaging is integral to the initial diagnosis of patients with a suspected aortic dissection; and should consist of multi-detector computed tomography (MDCT), transesophageal echocardiogram (TEE) or magnetic resonance imaging (MRI) based on the patient stability and institution capabilities. In this chapter we review MDCT, MRI and angiography in the setting of acute aortic dissections in regards to protocol considerations, proper measurement techniques and features which should be included in diagnostic reports due to their implications on immediate management and prognosis.

Patients who undergo redo coronary artery bypass grafting (CABG) are older, have more comorbidities, and a greater atherosclerotic burden than those who undergo primary CABG. In addition, redo CABG is technically more demanding than primary CABG. Sternal re-entry may be challenging because of the proximity of cardiovascular structures, including previous bypass grafts that could be at risk for injury. Furthermore, dissecting out the heart to institute cardiopulmonary bypass and exposing the coronary targets may be complicated by scar tissue and suboptimal dissection planes, with additional risk of injury to patent conduits or inadvertent manipulation of diseased conduits that can result in thromboembolic complications and ischaemia. Effective myocardial protection is especially important in redo CABG, and anatomical limitations must be overcome in patients with severe diffuse native disease or areas supplied by occluded grafts. Patent left internal thoracic arteries in redo CABG patients introduce an extra level of complexity in intraoperative management.

Objectives Reoperation for structural valve deterioration (SVD) of bioprosthetic mitral valves carries a presumed high operative risk, and transcatheter mitral valve-in-valve implantation has emerged as an alternative. However, surgical risk and long-term outcome following mitral valve re-replacement in these patients remain ill-defined. Hence, we sought to evaluate outcomes and long-term survival following surgical mitral valve re-replacement and to identify risk factors for mortality. Methods From January 1990 to January 2017, 525 patients underwent surgical mitral valve re-replacement at Cleveland Clinic for bioprosthetic SVD: 133 (25%) isolated operations and 392 (75%) with concomitant procedures. Surgical complications and modes of death were compiled, long-term mortality assessed, and risk factors identified using a multivariable nonproportional hazards model and random forest analysis. Results SVD was characterized by bioprosthetic regurgitation in 81% (425 out of 525) and stenosis in 44% (231 out of 525). One in-hospital death occurred after isolated valve re-replacement (0.75%) and 28 deaths occurred (7.1%; P = .003) after nonisolated re-replacement, 19 (68%) of which were from coagulopathy, vasoplegia, and multisystem organ failure. In the nonisolated group, incremental risk factors for time-related death after re-replacement included New York Heart Association functional class IV symptoms, concomitant coronary artery bypass grafting, prolonged cardiopulmonary bypass time, and transfusions. Conclusions Mitral valve re-replacement for bioprosthetic SVD was associated with low surgical risk and excellent long-term survival. Isolated mitral valve re-replacement for bioprosthetic SVD had near-zero surgical risk. Excessive cardiopulmonary bypass duration and multiple transfusions correlated with increased early mortality in nonisolated procedures, as did preoperative severe heart failure. Optimal surgical plan and timing of surgery are keys to success.

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis (AS) and is widely used to treat patients at all levels of surgical risk. Nevertheless, newe...

IMPORTANCE The impact of pre-existing cognitive dysfunction on outcomes after transcatheter aortic valve replacement (TAVR) remains unclear. OBJECTIVE To study the association between dementia and post-TAVR outcomes. DESIGN Cohort study with propensity-score matching was conducted using the Nationwide Inpatient Sample. EXPOSURES History of dementia at the time of undergoing TAVR. MAIN OUTCOMES All-cause in-hospital mortality, stroke, bleeding requiring transfusion, acute kidney injury, post-procedural vascular complications, post-procedural pacemaker implantation, length of stay, in-hospital delirium, and discharge disposition in patients with and without dementia undergoing TAVR. RESULTS Of 57,805 patients undergoing TAVR, 2910 (5.0%) had a diagnosis of dementia. Propensity-score matching yielded 2895 matched pairs of patients. TAVR was associated with an increased risk of bleeding requiring transfusion (14.7% vs 8.6%, odd ratio (OR) 1.82 [95% confidence interval (CI) 1.26-2.63]; p

BackgroundThe growing awareness of cardiovascular toxicity from cancer therapies has led to the emerging field of cardio‐oncology, which centers on preventing, detecting, and treating patients with cardiac dysfunction before, during, or after cancer treatment. Early detection and prevention of cancer therapy–related cardiac dysfunction (CTRCD) play important roles in precision cardio‐oncology.Methods and ResultsThis retrospective study included 4309 cancer patients between 1997 and 2018 whose laboratory tests and cardiovascular echocardiographic variables were collected from the Cleveland Clinic institutional electronic medical record database (Epic Systems). Among these patients, 1560 (36%) were diagnosed with at least 1 type of CTRCD, and 838 (19%) developed CTRCD after cancer therapy (de novo). We posited that machine learning algorithms can be implemented to predict CTRCDs in cancer patients according to clinically relevant variables. Classification models were trained and evaluated for 6 types of cardiovascular outcomes, including coronary artery disease (area under the receiver operating characteristic curve [AUROC], 0.821; 95% CI, 0.815–0.826), atrial fibrillation (AUROC, 0.787; 95% CI, 0.782–0.792), heart failure (AUROC, 0.882; 95% CI, 0.878–0.887), stroke (AUROC, 0.660; 95% CI, 0.650–0.670), myocardial infarction (AUROC, 0.807; 95% CI, 0.799–0.816), and de novo CTRCD (AUROC, 0.802; 95% CI, 0.797–0.807). Model generalizability was further confirmed using time‐split data. Model inspection revealed several clinically relevant variables significantly associated with CTRCDs, including age, hypertension, glucose levels, left ventricular ejection fraction, creatinine, and aspartate aminotransferase levels.ConclusionsThis study suggests that machine learning approaches offer powerful tools for cardiac risk stratification in oncology patients by utilizing large‐scale, longitudinal patient data from healthcare systems.

Introduction: New permanent pacemaker (PPM) requirement has been linked with left ventricular dysfunction after TAVR. Objective: We sought to study the impact of new PPM on echocardiographic outcomes after TAVR with SAPIEN-3 (S3) valve. Methods: We included consecutive patients who underwent TAVR with S3 valve at the Cleveland Clinic between April 2015 and December 2018. Patients with prior PPM were excluded. Echocardiograms were reviewed to determine left ventricular ejection fraction (LVEF), left ventricular end diastolic volume index (LVEDVi), left ventricular end systolic volume index (LVESVi), left ventricular dimension during diastole (LVDd), posterior wall thickness during diastole (PWTd), interventricular septum during diastole (IVSd), right ventricular systolic pressure (RVSP), inferior vena cava (IVC) diameter and tricuspid regurgitation (TR) grade. Results: Among 886 patients, the rate of 30-day PPM was 10.2%. Baseline LVEF was similar between new PPM and no PPM (55.4 ± 12.7% vs. 57.2 ± 11.2%; p = 0.188). There were no differences in the other studied echocardiographic parameters at baseline. Among patients with new PPM, LVEF was lower at both 30 days (54.4 ± 11.3% vs. 58.4 ± 10.1%; p = 0.001) and 1 year (54.2 ± 12% vs. 59.1 ± 11.3%; p = 0.009) compared to no PPM with Δ LVEF -0.9% vs. +1.4%; p = 0.023. There were no differences in LVEDVi (52 ± 20.8 vs. 48.3 ± 17.6; p = 0.186) at 1 year. LVESVi was higher with new PPM (24.8 ± 16.1 vs. 20.2 ± 10.9; p = 0.038). However, Δ LVESVi was similar between the 2 groups (-1.6 vs. -2.6; p = 0.517). There were no differences in RVSP (38.9 ± 14.1 vs. 40 ± 14; p = 0.58). LVIDd, PWTd, IVSd and IVC diameter also did not show variations whether patients were paced or not. Moderate to severe TR rates were similar as well (17.7% vs. 21.5%; p = 0.407). Conclusion: Among S3 TAVR recipients, new pacing requirement had a detrimental impact on LVEF at both 30 days and 1 year. However, it did not seem to affect the other studied echocardiographic outcomes after TAVR.

Introduction: Transcatheter aortic valve replacement associated infective endocarditis (TAVR-IE) is a relatively rare complication of TAVR. Little is known about the characteristics of early, intermediate versus late onset TAVR-IE. Methods: We studied the risk factors, microbiological patterns, diagnostic and treatment strategies in patients with early (1 year) TAVR-IE. Results: Ten out of 494 definite cases of prosthetic valve IE between 2007 and 2019, were confirmed to have TAVR-IE from the IE registry at our center. The mean age was 78.1 ± 13.7 years, with 50% being female. Most (90%) TAVR procedures were performed via transfemoral route, and one underwent transapical TAVR. Baseline comorbidities were common, with mean BMI 33.1 ± 5.5 kg/m2, diabetes and hypertension in 60% and chronic kidney disease in 50% of cases. Mean STS risk score was 7.8 ± 5.7. Most (60%) TAVR-IE cases had intermediate onset, with Staphylococcus aureus being the most common organism (66.6%). Diagnostic modalities and complications are described in Table 1. Two cases had early onset TAVR-IE, one of which was due to Pseudomonas aeruginosa, and underwent successful surgical treatment. Late onset TAVR-IE was observed in 20% of cases. 18-fluorodeoxyglucose positron emission tomography (18-FDG-PET) aided in diagnosis of TAVR-IE in 20% of cases. Mortality due to IE was observed in 40% of cases. Most of the patients underwent conservative management, and 37.5% survived over a mean follow up of 709 ± 453 days. Two patients underwent surgery, of whom one died day 30 post-operatively from sepsis. Mortality due to IE occurred in 25% of cases in the early and intermediate onset groups, while there was 100% mortality in the late onset group. Conclusions: In a single-center cohort, most TAVR-IE cases had an intermediate onset, with Staphylococcus aureus being the most common organism. Late onset TAVR-IE was associated with higher mortality at follow-up.

Introduction: Pre-existing atrial fibrillation has been linked with poor outcomes among patients undergoing transcatheter aortic valve replacement (TAVR). Objective: We sought to study the impact of baseline atrial fibrillation/flutter (AF) on outcomes after TAVR with SAPIEN-3 (S3) valve. Methods: All consecutive patients with severe symptomatic aortic stenosis who underwent TAVR with S3 valve at the Cleveland Clinic between April 2015 and December 2018 were included. Results: We included 1028 consecutive patients. Overall, the mean age of our study population was 81 ± 8.9 years, 58.8% were males, 95.8% were Caucasians. Pre-existing AF was present in 432 patients (42%). STS risk score was higher with AF compared to no AF (6.7 ± 3.8% vs. 5.4 ± 3.4%; p < 0.001). Baseline left ventricular ejection fraction (LVEF) was lower with AF (54% vs. 58%; p < 0.001). The rates of 30-day permanent pacemaker (PPM) implantation were similar between AF and no AF (11.4% vs. 9.4%; p = 0.326), as were the rates of new-onset left bundle branch block (LBBB) at discharge (9.6% vs. 9.4%; p = 0.901). There was also no difference in stroke rates at 30 days between the 2 groups (1.6% vs. 1%; p = 0.385). Post-TAVR mild or greater aortic regurgitation (AR) was higher with AF compared to no AF (21.5% vs. 16%; p = 0.022). LVEF was lower with AF at both 30 days (56% vs. 58.5%; p < 0.001) and 1 year (56% vs. 59%; p < 0.001). However, the change in LVEF (Δ) after TAVR was similar between AF and no AF (+1.1% vs. +1.4%; p = 0.624). At 2 years, all-cause death was higher with AF (22.9% vs. 12.8%; log-rank p = 0.011). There was no mortality difference between persistent versus paroxysmal AF (log-rank p = 0.714). Conclusions: Among our S3 TAVR patients, AF did not affect PPM, new-onset LBBB or stroke rates after the procedure. AF was associated with higher mild or greater AR at 30 days, as well as lower LVEF at both 30 days and 1 year compared to no AF. There was significantly higher all-cause mortality in the AF group at 2 years after TAVR.